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FEE WORKSHEET PER EACH FACILI- <br /> �W FACILITY <br /> DBA Q JJ CowtPA $- Y ADDRESS AE/NZ 6f SA 75 E //A S7- <br /> MAILING <br /> TMAILING ADDRESS 19a, /3ok 300/0 , SZaC&zo't/ CR '9,52- ( 3 —bow C-4 `/S37G <br /> PAYMENT <br /> i. Operating Permit Application/Annual Inspection Fee RECEIVED <br /> a. First Tank at Facility @ $150. MAR 111981 /So - <br /> b. Additional Tanks (# Additional Tanks x $50) .ENVIRONMENTAL HEALTH �- <br /> 2. State Surcharge (per tank) (Due with Permit Application, PERMITISERVICES <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total #/ Tanks) '56 - <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceased but :.;here the owner/operator proposes to <br /> re-use tank within 2 years. <br /> (#— Temporary closures x $80) (See above #3 to calculate surcharge) -01- <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 $90) <br /> Total Number of Tanks / Total Fee Due 2 0 (o <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 /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <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 /> 2-86 "& X60 <br /> 0C7 <br />