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FEE WORKSHEET <br />DBA N E <br />ADDRESS MWILIH <br />0 <br />NI9AWJ4 <br />E►2S <br />0 <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />b. Additional Tanks (#-0— Additional Tanks x $50) <br />2. State Surcharge (per tank) (Due with Permit Application, <br />on renewal or amendment of operation permit) <br />($,56 x Total ?�_� 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 2 years. <br />(#n Temporary closures x $80) <br />4. *Permanent Closure (per tank) Underground Storage Tank in which <br />storage has ceased and where the owner/operator has no intent <br />of re -using tank within next 2 years. <br />(# 0 Permanent Closures x $90) <br />Total Number of Tanks <br />Total Fee Due <br />C �} <br />X/1-5-0,00 <br />� <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet Q"Y-1- <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 />la. Existing Facility & 1st Tank $150 <br />b. 3 Additional Tanks x $50 150 <br />2. State Surcharge, 4 Tanks x $56 224 <br />Total Number of Tanks 4 Total Fee Due P�!Iv <br />�ave[,,, <br />27►'�lv��{*Both closures will be conditioned. Contact a Health District Repree. <br />HEALTH <br />12/85 <br />P WT//SEfVICEES <br />