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FEE WORKSHEET PER EACH FACILITY• 0 <br /> Y <br /> DBA � � �� a���. �Z 1�x� ADDRESS FACILIT <br /> MAILING ADDRESS_. ,Qp <br /> M <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank-at ,Facilit-v @ $150. <br /> b; Additional Tanks (1' 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 /> ($56x Total N Tanks) <br /> 3• *Temporary Closure (per tank) Underground Storage Tank in which <br /> R'' > <br /> storage has ceased but where the owner/operator proposes to . <br /> re-use tank within 2 ,yearsc <br /> (#_ Temporary closures x $80) (See above 13 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 /> Permanent Closures x $90) PAYMENT f�U <br /> RECEIVED <br /> 5. Plan Check Fee $30. ,. <br /> MAR 0� 1 87 <br /> FWRC)N�F�TA ('� AhTH l U <br /> Total Number of Tanks 1TI;�Q✓�Ct <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check <br /> r p3 <br /> �yq <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular, 1 unleaded, i supreme, 1 waste oil ) <br /> A: <br /> Ia. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 1500 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> �r_a <br /> Ye <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> 600"1 WIN <br /> 2-8e, 4 m tk akk <br /> 4 L <br />