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V . .✓ <br /> FI-E WORKSHEET p' /� G <br /> DBA �fVY Z1 lJ (1p�L IV / <br /> ADDRESSC� GT3 6 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <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 /> - — \wXTotal nY 7ian1n.-.l� <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 ) <br /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 <br /> Total Number of Tanks 4 Total Fee Due $52 i98ti <br /> JAN 21 <br /> ENVI RMIT/S'ERVICESENTAL LTH <br /> *Both closures will be conditioned. Contact a Health District RepresentatFf . <br /> 12/85 / <br />