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FEE WORKSHEET PER EACH FACILITY <br /> ` FAC'LT' <br /> `..e <br /> DBA ADDRESS a a q f a r K 11q0 e. m <br /> MAILING ADDRESS CGc feC- 6' <br /> PAYMENT <br /> 1. Operating Permit Application/Annual Inspection Fee RECEIVED <br /> a. First Tank at Facility @ $150. SEP 2 ? 1y88 <br /> b. Additional Tanks (/ Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application. ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <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 f3 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 /> (I Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> 107 , Sg Fevve�c� c_ <br /> Total Number of Tanks Total Fee Due so <br /> � <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 /> ( I regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility 8 1st Tank $150 <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 $524 <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> EH 23 032 2/86 <br />