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= t. <br /> FEE WORKSHEET t �^ <br /> DSA . <br /> ADDRESS d Vf3 <br /> 1. <br /> 3 .� --C •--+ --! �• <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a, Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $50) 35-Q <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total #-�A— Tanks ) <br /> '. *Tempo. ary ilosurc pc,, tuien) UnderQrg�in - S$rir^a-e Tank i- ch. <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 /> (4.43-- Pervanent Closures x $90) - <br /> Total Number of Tanks 4 Total Fee Dueg "� <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, I unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility & 1st Tank. $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Dotal Number of Tanks 4 Total Fee Due $524 V/i. <br /> r Ll r ; <br /> 9r Y , <br /> *Both closures will be conditioned. Contact a Health District Representative. JAN 2 2 <br /> ENVitRQjV1E,,NTAL HEALTH <br /> 1.2/85 E EH"4`iT,�SERV►C 5 <br />