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WORKSHEET <br /> to L' ✓ � D,, 98�3z <br /> bDRESS _— � <br /> I <br /> 1. Operating Permit Application/Annual Inspection Fee d <br /> a. Existing Facility and 1st Tank @ $150. Y <br /> b. Additional Tanks (# 3� Additional Tanks x $50) 15'0 <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 v, Total /f Ta.;.ks <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 �Z <br /> Make 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 /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 Ccsaw�0 <br /> Total Number of Tanks 4_ Total Fee Due $ 1986 <br /> - FEB 2 8 <br /> ENVIROMI HEALTH <br /> SERV CES <br /> *Both closures will be conditioned. Contact a Health District Representgf4%. <br /> 12/85 <br /> 4 <br />