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FEE WORKSHEET ,// <br /> DBA "eIOD/ /l�aTOPS Tiyc° bgN .COQ/ �v0/9 <br /> ADDRESS /,*a 1,1 40/r X19 . 7Sa�0 <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. c State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> 456 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 /> (#_ 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 /> (#_ Permanent Closures x $90) <br /> Total Number of Tanks Total Fee Due _?OZ_oo <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed applicatign. <br /> _ _ .=_"� _ �,-s-.,r.,�-moi:=--� � =':_ ,=— -: -'-•—��-�--•.... -:_�.._-- <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 $1 <br /> b. 3 Additional Tanks x $50 1 )a���17 <br /> 2. State Surcharge, 4-Tanks x $56 2 Ise U <br /> ---FEB 2 8 1986 <br /> Total Number of Tanks _4 Total Fee Due $-WVIROMENTAL HEALT11 <br /> \ PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />