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FEE PIORKSHEET� 'j <br /> DBA t <br /> ADDRESS U - # 7 s6 SU <br /> Nv ` ��� a7 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> v"U <br /> a. Existing Facility and 1st Tank @ $150. S (� <br /> b. Additional Tanks (#_ / Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) >/ry <br /> ($55 x Total a Tank-) _-- <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 C2 Total Fee Due /a cc <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. <br /> PLE - Annual FeeJFacil - ty <br /> Facility with 4 Tanks <br /> 301a.0 <br /> OLr§,,ularunleaded, 1 supreme, 1 waste oil ) <br /> r 1a..0 'Existi & 1st Tank $15 <br /> q A-ddial Tanks x $50 15 <br /> 124�fit aSO <br /> charge. 4 Tanks x $56 22 MAR 2 U 19tsb <br /> f Tanks 4 Total Fee Due $52tNVIROMENTAL HEALTH <br /> Total NumbeJ <br /> t <br /> FERMIT/SERVICES <br /> 1 _ <br /> 4Both clo V9 0e ?wilr be con rtioned. ;ontact a Health District Representative. <br /> y ./ <br />