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✓ fACILIIY <br /> 8A Ey.1- r"A� ADDRESS cfGnl <br /> AILING ADDRESS S <br /> operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (f Additional Tanks x $50) <br /> State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit andtemporary closure) <br /> ($56 x Total 1 Tanks) <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 within 2 years. <br /> (1_ Temporary closures x $80) (See above 13 to calculate surcharge) <br /> I. 'Permanent Closure (per tank) Underground Storage Tank 1n which <br /> storage has ,ceased and where the Qwner/operator has no intent <br /> of re-using tank, <br /> (f 7YPermanent Closures x $90) <br /> S. Plan Check fee $30. <br /> b <br /> Total Number of Tanks Total Fee Due fo <br /> l <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> EXAMPLE - Annual fee for facility with 4 Tanks <br /> SEMCO 1328 <br /> TERRY HAMILTON, PRESIDENT <br /> RICHARD C. HAMILTON, V.P. p <br /> li PH. 209-524-9651 - -._19-�/f- 90-1314/1211 <br /> 0.11 . HATCH ROAD V <br /> MOD STD, CA 95351 <br /> PAY TO THE -I^C�- -I $ I dpo <br /> ORRDDEER OE_ - <br /> l/r UNION SAFE I <br /> fLlt".��\ <br /> DEPOSIT <br /> •Both cle BANK BANN <br /> .aoo awa..r.sra. <br />