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f <br /> FEE WORKSHEET <br /> DBA -k'ti t S t �L �v'a�t ��- •t <br /> ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# 2 Additional Tanks x $50) /00 <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> i$5C A Total # Tanks) i <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 3 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 /> Ia. Existing Facility & lst Tank <br /> b. 3 Additional Tanks x $50 <br /> L� L <br /> 2. State Surcharge, 4 Tanks x $56 '1986 <br /> Total Number of Tanks 4 Total Fee DueEN&6kNTAL HEALTH <br /> FERMIT/SERVICES. <br /> *Both closures will be conditioned. Contact a }health District Representative. <br /> 12/85 <br />