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FEE WORKSHEET e, b ON Ko ID <br /> DBA gahK off . S�ck+an _ F?O. Qo�C l//d S{-oC(�fn•t �'41i� 9i L� 1 <br /> ProPeR+y <br /> ADDRESS 99 S�ocK.'{-on C!e 9SZ/Z <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. ($O OO <br /> b. Additional Tanks (#_,3 Additional Tanks x $50) D �a <br /> 2. State Surcharge (per t�nh) (Due with Permit ,lpplication, <br /> on renewal or amendment of operation permit) <br /> \r5 "--YI-- '% d <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 /> (# Temporary closures x $80) <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 /> Total Number of Tanks -/ Total Fee Due Ea5/•e_ <br /> �Y �g <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. m 2� <br /> — ADMINISTRATION — <br /> EXPENSE ACCOUNT #3 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks G/L #90 ._ <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) APPROVED <br /> Ia. Existing Facility & lst Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 / <br /> Total Numhor of Tanks 4 1,16 ' �Sb <br /> O.R.E. 5 .90 <br /> JAN 2 6 �� O gQ-5\\53`3 <br /> *Both closures will be conditionea._Contact a HealthU� <br /> Dive. <br /> PERMIT <br /> 12/85 <br />