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FEF WCRKSHEET <br /> DBA t:- • 1e• 6ar � P-A+nc 6b , <br /> ADDRESS 4r4 r L6 !'�-� I?A711 co <br /> 1. Operating Permit Application/Annual inspection Fee w <br /> a. Existing Facility and 1st Tank @ $150. �d <br /> b. Additional Tanks (# Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, a <br /> ± on renewal or amendment of operation permit) <br /> ($56 x Total # Tanks) <br /> Temipoi ar y C'o ^w (pLr-tanl ;_.1lnr� rnrn�,�,� Sra:g.e.=Tank_in i.ch - <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> f (# 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 <br /> EXAMPLE -- Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & lst TankWi <br /> $1 <br /> b. 3 Additional Tanks x $50 IMAR <br /> pr= <br /> fj{Sl41 <br /> 2. State Surcharge, 4 Tanks x $56 1 9 1986 <br /> Total Number of Tanks 4 Total Fee Due $S"VIROMENTAL HEALTH <br /> PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />