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ILL WORKSHLL1 PER EACH FACILITY <br /> .,. FACILITY ... <br /> DBA ij F//AIF.Pf?G fI�PE/ ADDRESS <br /> MAILING ADDRESS Sf/A�If yS3 <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (p 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 N 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 /> (q_ Temporary closures x $80) (See above N3 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 /> (HPermanent Closures x $90) 9V <br /> 5. Plan Check Fee $30. <br /> Total Number of Tan- — ' Total Fee Due 0 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> PAYMENT <br /> RECEIVED <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> JUN 5 1987 �-Ofa-q <br /> ( 1 regular, 1 unleaded, 1 supreme, l waste oil ) ENVIRONMENTAL HEALTH <br /> la. Existing Facility & 1st Tank $150 PERMITJSERVICES <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. JUN 5 1987 <br /> 2-t16 ENVIROMENTAL HEALTH <br /> PERMIT/SERVICES <br />