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FEE W RKSHEET njXZ <br /> EACH FACILITY • <br /> pp FACILITY <br /> 08A _ N 4 &)-n�J (y I'T ADDRESS <br /> MAILING ADDRESS P O X <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (1' Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application. <br /> on renewal or amendment of operation permit andtemporary closure) <br /> ($56 x Total N Tanks) <br /> 3. `Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> (/_ Temporary closures x $80) (See above N3 to, calculate surcharge) <br /> 4. *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the 9wner/operator has no intent <br /> of re-using tank, <br /> (N I Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> fLD <br /> Total Number of Tanks Total Fee Due % <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> PAYMENT <br /> ur check. RECEIVED <br /> SEMCO <br /> TERRY HAMILTON, PRESIDENT 'd <br /> EXAMPLE - Annual Fee f1 RICHARD C. HAMILTON, V.P. 1366 <br /> PH. 209-524-9659 <br /> ( I regular, 431 W HATCH ROAD _(�—-_ 19_Y(_ 90-1314/1211 <br /> Ia. EXl$t1D LI PORDER <br /> HYTO THE M ESTO, C`�95351 J $ 1 � j <br /> b. 3 AddiC , (� <br /> DOLLAR S <br /> 2. State 5 : UNION SAFE <br /> DEPOSIT <br /> Total NumberNNMEM DANK <br /> I' a Sara.CA 9s 68 <br /> �L'•• —••••••.,ei'�+eY9®4GPtl4W:u�ce�M.:._=:e.YWW51C4 bY@'d.0 <br /> "Both closures will be C011uF1,FVnw. <br /> 2-RG <br /> UGC � 1 <br />