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FEE WORKSHEET <br /> DBA _ hs C". /SkiQGP, <br /> ADDRESS L{ 05 QQ -W - <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <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 /> ($56 Total T,-k, <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 N Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. <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 Q V�� �P•. <br /> b. 3 Additional Tanks x $50 150 �( <br /> 2. State Surcharge, 4 Tanks x $56 224 FE8 2 5 1960 <br /> Total Number of Tanks -4 Total Fee Due $524 ENVIROMENTAL HEALTH <br /> F ERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> X85 <br />