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,BEET <br /> �`' v t toe <br /> .,,,ADDRESS UO <br /> 1. Operating Permit Application/Annual Inspection Fee , <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. ' Additional Tanks ( Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ( 5 x Total # - . Tanks) <br /> _-.--- <br /> 3 �empora.r�Clos�;re�4-pea"=ta.n:k:}�Ur�dea�g.round-S-tor_age:San,k i•E�—a�h�:ch -� --_ ---- ..-�. .� -- -_ ---� <br /> storage has ceased but where the owner/operator proposes 'to <br /> re-use tank within 2 years, <br /> (# Temporary closures x $80) <br /> 4. *Permanent Closure (per tank) Underground Storage Tank i,n whish <br /> storage has ceased and where' thel owner/operator has no intent <br /> This is to t:ertrly that the products or servrceS <br /> of re-using tank within next 2 years. hereon t,ave Meer;r, !, '",-T0 r'•»Il,d ar <br /> (# Permanent Closures x $90) this ii ac is It re 'rluJEQfc"(�aYiir itt <br /> Oktu e' Statins, + <br /> P,C� <br /> v Total Number of Tanks � j-�.c.[..6 Sa .Tot _ ,Z. o b UO <br /> i►i <br /> ways Date Au nut t <br /> 01 !hgS ISO DU <br /> Er;perise Ge t rtption <br /> Make all fees payable to San Joaquin Local Health District. rnclose this worksheet <br /> with your check and the completed application., <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. . Existing Facility & 1st Tank $150 <br /> 4- i <br /> b. 3 Additional Tanks x $50 15 <br /> 2. State Surcharge, 4 Tanks x $56 ctaw O <br /> Total Number of Tanks 4 Total Fee Due 52f E B 3 r��n <br /> ENVIROMENTAL. HEALTH <br /> h PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact_a Health District Representative. <br /> 12/$5 <br />