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-r � oRE S erio his <br /> , T <br /> uc7 <br /> MAILING AOORESS o, box lo7q 3 <br /> r� <br /> t i'enr�tAA <br /> caod, tr, oai�nsg � .�� ee..; <br /> Ft �a�ekFa <br /> b. Additional Tanks '(# Add itions I Tanks x $50) <br /> State . urcharge�f per}�tank Oue with>, <br /> 2' S ) ( Ptl<mi t .Application. <br /> . on ren`ewal•'or ari MkIent of o ration rmi L, <br /> Pe Pe and tasapa,rarr closure) <br /> (S56 x-Total I Tanks) <br /> • <br /> *Temporary. Closure. (per -tank) Underground-Storage Tank in which <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank wi thin 2,,years. <br /> Temporary. <br /> •losures�lx 4804..(Soe:--above> 13 to calculate surcharge) <br /> ? ermae > ::;� �'^epet, tank) 'underground <br /> Storage Tank in which <br /> : storage figs ceased and where the owneroperator has no intent r <br /> of iie;-ustiig stank 4= ! <br /> ( Permanent Closures x S90) = � �cp° <br /> Plan Check Fee S30 <br /> �riaivld.er C20d DD <br /> Total Number of Tanks Total Fee Ove ar DO <br /> ke all fees payable to San Jo a uin Local Health District. Enclose this worksheet <br /> ith your check <br /> jrx <br /> EXl1"1��c t�nnu.til F ��+ for- F,lci l i ,k wr tlr w 1.1rot, <br /> { I r •r,u I .�r . I ,n I .11 • 1 , ! ,rrpa- •r:•• I k•. . , : 7 } ''I <br /> l,r . f. rS [ rrrrl I ,1r ilrt ., 3',t �,1nL SIY1 <br /> 1i. 3' :,r1rt s [ terra I I.rir� S�fl 1 X11 <br /> Statr° Sureharq, 4 Tank, k S50 2�'4 <br /> 10tal Number of Tdnk., 4 total Fee Oue 5524 <br /> th closures will be .conditioned.-Contact a Health Oistriet Re resentativ'e: <br /> G <br /> t •'Sri. s �_ •,rte;'' a � c: - .. - _ti•. . :� , '.t r7.r.• •1 <br />