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F't . WORK:SHEET PER EACH fACII 1*v 4'600 Act_ Pcpad <br /> FACILITY AQatl ,� 95220 <br /> D;1:, Lodi Unified School DlstN"tt AODRESS <br /> Pry ILING ADDRESS <br /> New Facility or Addition <br /> i <br /> a. First Tank $180. <br /> b. Additional Tanks (H Add�itionaT Tanks x $5tl) <br /> q <br /> 2 . Operating Permit Application/Annual tnspection' Fee," ' <br /> a. Existing Facility and 1st `Tank @ $150. <br /> b. Additional Tanks (N Additional .Tanks x $59)' � <br /> Statc Surcharge (per tank) ,,(Diue with Permit 'Applicati'on, <br /> on renewal or amendment of operation permit and temporary closure):' , <br /> (556 x. Total N Tanks),I <br /> c 'Temporary Closure (per tank) Underground 5toe�'ge'"Ta,,ok i'nwhich <br /> storage has ceased but where the owner/operator pYopose's to <br /> re-use tank within 2 years: , <br /> ( ' Temporary closures x' $80) (See above Iia tolca,lcylate 5urcjiarge) <br /> Closure (per tank') Underground S;korage 'T'ank' in which: � <br /> star;; , �1as ceased and where the owner/epera, tor has 'no intent <br /> I <br /> f r.� r i ng tank wi thin next 'yea'ns. - 90. <br /> nn. +: eLnt Closures x $90) <br /> Total Number of Tanks , <br /> 'Total Fee' Due' 90• <br /> make all fees payable to 4 <br /> San doa uin Local 'Health District; Enclose thi's worksheet, <br /> rr, th your check . <br /> i <br /> EXA14Pl.E_ AnnuaFee- l Ffor Facilityjwith 4, Tanks <br /> -- regular, 1 u leaded 1 suP.�em <br /> 1 waste oil ) <br /> Ia . Existing . Facility & 1st Tank $150 <br /> 150 <br /> b. 3 Additional Tanks ; $50 • <br /> , <br /> 2. State Surcharge, 4 ,Tanks x4$56 <br /> 224 <br /> Total Number of ,Tanks 4' Total Fee Due' $524 <br /> �5oth closures will be conditioned Cohtact a''Heal th' District Representative. ' <br /> I <br /> i I �: I r�i,f' I.'�f^�M.w.,.•arw..rrs. v.,wrys-n.�w.'_ <br />