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FEE WORKSHEET <br /> DBA (In om 11nG Rd �� I J 2A�ys �Fr2 i /V f <br /> ADDRESS 14vE Nu` 1,AThQaloe � Nig <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. Sp.op <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) <br /> i¢16 „ Total # T_n ,_� <br /> \V'w n Total UnnJ/ <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 /> 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 _ <br /> � Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet Q,' <br /> with your check and the completed application, yvg <br /> EXAMPLE. - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 22 a(yj�r�(�D <br /> Total Number of Tanks 4 Total Fee Due $52 JAN 2 7 WO (1`�(/�//j <br /> ENyFmuMENTAL HEALTH <br /> *Both closures will be conditioned. Contact a Health District RepresentafERveANTRRVICES <br /> 12/85 <br />