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FEE WORKSHEET <br /> DBA MARCI ' S DIESEL SERVICE , INC . <br /> ADDRESS 2969 Loomis Rd . Stockton , Ca . 95205 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @' 150: <br /> b. Additional Tanks (# Additional Tanks x 650)y <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> Kr A, v Total # _ Tankg1 <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) <br /> O4 *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> of re sing tank within next 2 years. <br /> Z-Permanent Closures �90) &O . <br /> 1. 8.0, 00 <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 and the completed application. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks � t � <br /> d � <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> FEB 2 5 1y8b <br /> la. Existing Facility & 1st Tank $150 <br /> b: 3 Additional Tanks x $50 1MVIROMENTAL HEALTH <br /> 2. State Surcharge, 4 Tanks x $56 n 224 FERWII//SERVICES <br /> Total Number of Tanks 4 Total Fee Due p %1V11 11 <br /> JAN 2 8 06 <br /> *Both closures will be conditioned. Contact a Health District Re RGli'VAL14EALTH <br /> PERMIUSE"WILS. <br /> 12/85 <br /> �.► 1.01 <br />