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LE WORKSHEET PER EACH FACILITY • • <br /> F FACILITY <br /> o nT_C'g /. _Ori ADDRESS nI ST / SO <br /> ILiNG ADDRESS �i11^� 2 ���. � • <br /> 1. Operating .Permit`Application/Annual-Inspection :fee <br /> a.% First- Tank 'at`Facillty 8 4150. , -' ` <br /> b. Additional Tanks(v eAdditional Tanks X450) # <br /> State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and. temporary closure) <br /> (S56 x Total f 2 Tanks) <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceasedbutwhere the owner/operator proposes to <br /> re-use tank-within 2,years. <br /> (f_'Temporary closures x $80) (See above /3 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 /> (f a Permanent Closures x $90) �O <br /> 5. Plan Check Fee $30. <br /> 1l�6t 7 C�4 ^p / <br /> Total Number of TanksTotal Fee e� � �`S2 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. PAYMENT <br /> RECEIVED <br /> EXAMPLE - Annual Fee for facility with 4 Tanks <br /> AUG 2 61987 <br /> ( I regular, I unleaded, 1 supreme, 1 waste oil ) ENVIRONMENTAL HEALTH <br /> la. Existing Facility b 1st Tank $150 PERMITISERVICES <br /> b. 3 Additional Tanks x 150 150 <br /> 2. State Surcharge, 4 Tanks x 156 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> *Both closures will be conditioned. Contact a Health District Representative_ <br /> 2 -AG <br />