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i vv t� -10bUf-MORE$$ 0 r (A/Aske <br /> WILING ADDRESS Pr 0, a� p • 3 <br /> WiFf', <br /> tn9:Per>Ai! cat c :. uii: eis "cil 69 <br /> , <br /> S <br /> r <br /> b. - Additional :T&nks"(1 Adds tional .Tanks--x $50) <br /> 2 . S to te':Surcharge ,(peri tanks (Due wi th>Perai t plication, <br /> ohrenewal or amendment of operation:-perait• and teffoorary closure) <br /> 4.56 x'"Total 1 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 Z_,years. <br /> Tempoa <br /> TOlosures $80) ,(Seen"above; 13 to calculate surcharge) ' <br /> etank) 'Ainderground Storage Tank in which <br /> storage :Y. <br /> has ceased and where the owner(operator Das no intent <br /> of;ire:-usliigenk _�,� t f r(A" ' <br /> 2 Permanent Closures u <br /> Plan Check Fee 530. � �0• ap e,Wlct-i od-e r <br /> Total Number of Tanks u Total Fee Due00 <br />'ike all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> ith your check . <br /> tt& <br /> CX A-,iP( hrtrtu.ti 1 Fr,k, (nr' Fac t I t (v wt I h 7 .crit <br /> ( I rtt;ub .lr' . I urll11,101• I , 1 <br /> 1110 I ,1 r t l r • , c, I ( '.1 F1 <br /> 3 :,cir1 i ( 1 ona I 1.1114 1,A) <br /> �(Atr' lank% S) o 7?4 <br /> I <br /> Total Number of Tank% 4 lotal Fee Due 5524 <br /> Closuresl b , s` z 4:. <br /> ►+ a <br /> co a Health District Repr�esentati.'e <br /> ;G 3 7 <br /> kT `F <br />