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FEE WORKSHEET <br /> DBA <br /> ADDRESSW 119- 9Sao5 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. J _ <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) <br /> JELL- T-.a l J/ T,..1...1 -- - - - , <br /> ky . A .Vbnl n j iannO� `, <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 ..- <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 ) n <br /> Ia. Existing Facility & 1st Tank 'U/ �nrn(C3r� <br /> b. 3 Additional Tanks x $50 r���;4(jjy 50 v�( I`tlll►VU►1� <br /> 2. State Surcharge, 4 Tanks x $56 F48 b lybo <br /> Total Number of Tanks 4 <br /> Total Fee Due"WNTAL HEALTH <br /> F 1 /SERVICES <br /> *Both closures will be conditioned. Contact a Heal -.h District Representative. <br /> 12/85 <br />