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r LL WK&WiLL I PER EACH FACILITY <br /> _ �� FACILITY ,� / <br /> 03Ar►�Q$/1� r& � Aj7— ADDRESS �S-4�IV <br /> MAILING ADDRESS � <br /> 1 . Operating Permit Application/Annual Inspection Fee' <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (A Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total # Tanks) <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) (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 /> (N--L Permanent Closures x $90) PAYMENT <br /> REGEIVED <br /> 5. Plan Check Fee $30. <br /> ILLVIRONMENTAL HEALTH <br /> Total Number of Tanks HRM1TNA1USee Due <br /> 4Y"S <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check . f^/� <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 5150 i <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $52.4 <br /> "Both closures will be conditioned. Contact a Health District Representative. <br /> 2-11G <br /> . u <br />