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!`Et WORKSHLET PEEP EACH FACILITY �2 <br /> ACILIT <br /> DBA ( YYl VIUe L7 i[ e n. _ ADDRESSY LOAJ <br /> MAILING ADDRESS . <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ $150. <br /> b. Additional Tanks (N Additional Tanks x $50) <br /> 2• State Surcharqe (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total A 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 /> (d_ Temporary closures x $80) (See above N3 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 /> (6--L Permanent Closures x $90) � <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due RD ' <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check_ <br /> PAYMENT <br /> RECEIVED <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks JUN 14 1988 <br /> ( 1 regular. 1 unleaded, 1 supreme, 1 waste oil ) <br /> ENVIRONMENTAL HEALTH <br /> Ia. Existing Facility 8 1st Tank <br /> ��I�IT�SERVICES <br /> b. 3 Additional Tanks x S50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> 'Both closures will be conditioned. Contact a health District Representative. <br /> 2-ar, <br />