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FEE WORKSHEET (� <br /> DBA , ����Y������'- —n------ -- - —,, <br /> ADDRESS X21 !_—�JLft�J//' --5 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $50) 0 0 D <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) pp <br /> ($56 x Total #—S—� Tanks) O� <br /> *1 - <br /> rl 1.....- aa- N Undergrcund Storage Tank in �,;h,ch <br /> .�, empor ary Closure (per 6ankl ., Storage <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 /> (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 $56 224 m <br /> Total Number of Tanks 4 Total Fee Due $` ;�e���V �O <br /> FEB <br /> 3 1y86 <br /> *Both closures will be conditioned. Contact a Health District Repres,'"ViRQMENTAL HEALN <br /> ARMIT/SERVICES <br /> 12/85 <br />