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FEE WORKSHEET <br /> DSA ` U <br /> ADDRESSrJe. <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. 'Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# 2Additional Tanks x $50) Q. <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> /art IT_s 'I u �f r __ G t' <br /> k,E1J 6 7. I IJ L Q I R '7 I d 1 1 k J <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 - / 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 /> 1a. Existing Facility & 1st Tank i150,vn <br /> b. 3 Additional Tanks x $50 4 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> E8--°- OU <br /> Total Number of Tanks 4 Total Fee Due 54At HEALTii <br /> r� <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br /> � i <br />