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FEE WORKSHEET PER EACH FACILITY • • <br /> �hDclzTo� buiNr FACILITY <br /> OBA <br /> �U�c,c ADDRESS <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ 5150. I� 01D <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 and temporary closure) <br /> 456 x Total N I 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 /> 0/ Temporary closures x $80) (See above f3 to calculate surcharge) <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. <br /> (/ � Permanent Closures x $90) J�SsouhCFis 9D• C7D <br /> 5. Plan Check Fee $30. C4�oll��(o <br /> M I Z-Z2-8-+- <br /> Total Number of Tanks 1 Total Fee Due �2q boD <br /> "c"c =$2O(o.CTz� <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheetl � ` s <br /> with your check. <br /> a Nk <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks ` • 157 <br /> ( 1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility b 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 PAYMENT <br /> 2. State Surcharge, 4 Tanks x f56 224 RECEIVED <br /> JAN 7 1999 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> ERVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 2-NG <br />