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FEE WORKSHEET PER EACH FACI14,.r <br /> FACILITY <br /> ADDRESS <br /> MAILING ADDRESS luClSfc «%� j <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ 1150. <br /> b. Additional Tanks (I / Additional Tanks x 150) —7� <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total N 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 /> (1'_ Temporary closures x $80) (See above /3 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 /> (® Permanent Closures x 190) PA Y M E N T <br /> RECEIVED <br /> 5. Plan Check Fee 530. <br /> JUN 10 1988 <br /> 'NVIRONMENTAL H <br /> Total Number of Tanks PERMIT/SERVIAKEWlee Due 136 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( I regular. 1 unleaded, 1 supreme, I waste oil ) <br /> Ia. Existing Facility b Ist Tank SI50 <br /> 1). 3 Additional Tanks x 150 150 <br /> 2. State Surcharge, 4 Tanks x 156 - . 224 <br /> Total Number of Tanks 4 Total Fee Due 5524 <br /> 'Doth closures will be conditioned. Contact a Health District Representative. <br /> 2-RL <br />