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FEE WORKSHCET PER EACH FACILITY <br /> FACILITY <br /> DBA 00e ADDRESS u r C�� Gt � <br /> J � <br /> MAILING ADDRESS /ie,✓ <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $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 and temporary closure) <br /> ($56 x Total 1 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 /> (#_ 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 /> (1/ Permanent Closures x $90) �� <br /> 5. Plan Check Fee $30. <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 . PAYMENT <br /> RECEIVED <br /> SEP 2 0 19dj <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> — ENVIRONMENTAL HEALTH <br /> ( 1 regular, 1 unleaded, 1 supreme. 1 waste oil ) PERMIT/SERVICES <br /> Ia. Existing Facility 8 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 5524 <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> EH 23 032 2/86 <br />