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FEE WORKSHEET <br /> DBA JWIIC6 C6gre <br /> ADDRESS ® , <br /> I <br /> Ke >e <br /> Loo/ , CA 9 524-0 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 50, � <br /> b. Additional Tanks (#—3Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> _($5£,-_Total Tar!4c) ---- <br /> 3. <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, n/ <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) N <br /> Total Number of Tanks If Total Fee Due J —7 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <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 $15 y, <br /> b. 3 Additional Tanks x $50 15 Q �1 1♦ 1 <br /> 2. State Surcharge, 4 Tanks x $56 22 „!!! (UJ <br /> MAR 4 'iytSu <br /> Total Number of Tanks 4 Total Fee Due $"iNVIROMENTAL HEALTH <br /> PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />