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T <br /> FEE WORKSHEET <br /> DBA 9 tCj Qdl1 Ulf �SkTQGIV% 73 <br /> ADDRESS 4 Qowcbar% S"Tv,*� Ck{cr% <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 3J,Sid 0O <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 /> ($56 Total_ TankE) V��W <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in which V <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 Zoo•fib <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 $56 224 (� <br /> Total Number of Tanks 4 Total Fee Due $524 09 �����1111 <br /> 1 1`1V�I+1 <br /> FEB 2 5 986 <br /> *Both closures will be conditioned. Contact a Health District RepresentatiUA RWENTAL HEALTH <br /> F ERMIT/SERVICES <br /> 12/85 <br />