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FEE WORKSHEET PER EACH FACILITY <br /> _{.— FACILITY <br /> DBA : l �n. / .? bhc F ADDRESSlTD12 ��11a`J <br /> 1 MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ $150. <br /> b. Additional Tanks (I 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 /> (S56 x Total k Tanks) <br /> 3• "Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceased but where the owner/operator proposes to <br /> I <br /> re-use tank within 2 years. <br /> (/_ 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 . PAYMENT a70 <br /> RECEIVED <br /> (# ,I Permanent Closures x S90) <br /> 5. Plan Check Fee 530. MAY 3 1 lydo <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES U <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check _ <br /> kIV <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular. I unleaded. 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility b 1st Tank 5150 <br /> b. 3 Additional Tanks x $50 ISO <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due 552.4 <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> 2 ->{L <br />