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FEE WORKSHEET .. <br /> DBA f// //ty C` <br /> ADDRESS <br /> 1. Operating Permit App, ication/Annual Inspection Fee <br /> a. Existing Facility and 1st ' ank @ $150. <br /> b. Additional Tank (# Ad it <br /> ional Tanks x $50) <br /> 2. State Surcharge (pe tank) (D)with Permit Application, <br /> on renewal or amendment—o- eration permit) <br /> (OSx Total9 Tanks) �Z�f <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 5-24 " <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 /> i (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 1D 9C�nl� <br /> 2. State Surcharge, 4 Tanks x $56 2 ((('"`'VVVV�+++�►►►►' <br /> - <br /> Total Number of Tanks 4 Total Fee Due-- $524-FEB 2 8 1986 <br /> ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES, <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />