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& t <br /> 1 <br /> FES Wt1RSHtET <br /> E <br /> s <br /> k <br /> DDFSS <br /> Xj <br /> 1. Operating Permit`Apel isati n/=annual " rr pe tion' Pe <br /> .. a nd l;st .Tan C a <br /> b Additional Tar ks `( Additi.orial Tank ` x <br /> 2: State Surcharge {per" tank) Due witri Peritpplicatian, <br /> 3 <br /> on renewal or amendmont of operation per-mit), <br /> ($56 x Total ► Tanks") <br /> v <br /> *Temporary C3osu�^e {por tank). Under rntn Lora ie Tank n which <br /> storage has ceased but where the owner/oper4tor proposes to <br /> re-use tank within 2 years. <br /> ( Temporary, closures x $ Q) ' <br /> 4' *Permanent Cl sure (per tank)" lnderg o�and Storage Tank in; Which <br /> 7 <br /> storage has ceased and where the. ownerAoperator� has: rio;intent ;.' <br /> of re-Fusing tank "within next. ,yre res,, <br /> r <br /> ( Permanent Closures $ 0) <br /> Total Number oil Tanks Total. Fee Due <br /> Make aT l fees payrabl e to San JQa ui ri ,oea ': Health bistrict. Enclose o e th,s, worksheet <br /> with your check and the completed appication� <br /> EXAMPLE - Annual Fee fcr Kaci l i t v th _Tan <br /> {1; <br /> regular,, ;1. unleaded g supreme g waste` di 1 ) <br /> 1a. Fxistirga�c71i y' & =s"t:Tangy $150 <br /> b. 3'Additional' Tanks °x <br /> . State Surcharge 4nks x N2 <br /> „ d <br /> Total . Number of Tab Total Fee Due 4 <br /> Both l osuros Will l be condi t errVVRO <br /> ed cortttt a lea l h [l str7 ct RdpAs <br /> 5 <br /> 12/35. <br /> } <br />