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FEE WORK-SHEET PER EEACI4 FACILIT <br /> DBA _ �'(J�IZF`c PeT i��Jl F1G (l//s FACILITADDRESS <br /> Y �/� <br /> MAILING ADDRESS PO, 60y- 67, 64u0-4 , C4LIF f5`�04 <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (d Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application. <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total N Tanks) <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 /> (N_ 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 . <br /> (®_ Permanent Closures x $90) <br /> 5. Plan Check Fee $30. �' <br /> • �((-1-.16(0 <br /> D'DLT©' Y <br /> Total Number of Tend-- ` ` Total Fee Due—'—"`'""'""` <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. PAYMENT PAYMENT <br /> RECEIVED RECEIVED <br /> C� +$ \3 \ 9� <br /> 198:' E; 193830 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ENVIRONMENTAL yyEALTH ENVIRONMENTAL HEALTH <br /> ( I regular. 1 unleaded, l supreme, }gEfR�l�fS PERMITJSERVICES <br /> Ia. Existing Facility 8 1st Tank 5150 <br /> b. 3 Additional Tanks x 850 150 <br /> 2. StateSurcharge, 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 /> I - —-- <br /> 2-fib <br />