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FEE WORKSHEET <br /> DBA SEIBOLD CORPORATION, Tje1VA/i7-Cof6RA <br /> ADDRESS STOCKTON, CA 95208 <br /> No7f% TAN K s 8,�, FRAPh 6�.�, y�� gzo s., ,�Oel"l sr <br /> s7ac �/ <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. �co <br /> c- <br /> b. Additional Tanks (# 2-- Additional Tanks x $50) D d <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) �([] <br /> /QC.G x Total t� Tanks) <br /> .� vwi n i¢nn�) <br /> 3. *Temporary Closure (per tank) Underciround Storage Tank in which <br /> storage has ceased but where the pwner/operator proposes to <br /> re-use tank within( rears. <br /> (#Q Temporary closures x $80) E <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 /> pp® <br /> Total Number of Tanks Total Fee Due <br /> t-4-h— <br /> Make <br /> 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 /> Ia. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 15� \� <br /> 2. State Surcharge, 4 Tanks x $56 <br /> ly r�"Z�r <br /> Total Number of Tanks 4 Total Fee MW4 <br /> ENVIP - XAE HEALTH <br /> FERM�T/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />