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FEE .IIORKSHCET PER EACH FACILi <br /> V e"" 1-a, 0- PDtit <br /> DBA ft PDM FACILITY <br /> ADDRESS z <br /> ►WILING ADDRESS Z3z� �4u DV <br /> 1• Operating Permit Application/Annual inspection Fee <br /> a, First Tank at Facility @ $150. <br /> b. Additional Tanks (/ Additionel Tanks x 150) (s w <br /> 2• State Surcharge (per tank) (Due with Permit A s <br /> on renewal or amendment of operation Permit Application. -�-- <br /> ($56 x Total / and temporary closure) <br /> Tanks) <br /> 3• 'icmporary Closure _ <br /> (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) (See above /3 <br /> to. calculate surcharge) <br /> 4• "Permanent Closure _ <br /> (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 /> (I_ Permanent Closures x $go) <br /> 5. Plan Check Fee $30. <br /> k <br /> i' <br /> Total Number of Tanks <br /> Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District <br /> Enclose this worksheet <br /> with your check <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> PAYMENT <br /> ( 1 regular, I unleaded, 1 supreme, I waste oil ) RECEIVED <br /> la. Existing Facility b 1st Tank <br /> b. 3 Additional Tanks x $50 $150 JA' IN <br /> 2• State Surcharge, 4 Tanks x S56 150 <br /> ENVIRONMENTAL HEALTH <br /> — 22A PERMIT/SERVICES <br /> Total Number of Tanks 4d Y zd-•w <br /> Total Fee Due $524 <br /> IIS-1frk <br /> 'th closures will be conditioned. Contact a Health District Representative. GL� <br />