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FEE WORKSHEET <br />' DBA <br /> ADDRESS —/ice!►' -� �X 3 cam+ `} i� �.3 , (,� <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. S U <br /> b. Additional Tanks (#. 'L Additional Tanks x $50) 10-0 <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total # 3 Tanks) <br /> !__._ Ilndorn�^nijnd CfnrAnp Tank in which <br /> 3. Tempor•dry C'Qu 1 F'e ��,�� �uti�n! - - <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 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (I regular, I unleaded, 1 supreme, I waste oil ) <br /> Ia. Existing 'Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 <br /> 2. State Surcharge, 4 Tanks x $56 I" <br /> Total Number of Tanks 4 Total Fee Due $5244,AR 5 <br /> ENV1R0-%,E N7AL HEALTH <br /> FM'dIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />