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FEE WORKSHEET //�� <br /> DBA -11A �fJ �f� /,l <br /> ADDRESS --z/ 3 �.SZD 3 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. c, <br /> b. Additional Tanks (# Additional Tanks x $50) / (a <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total #Tanks) 3 � ' <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 <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 8150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 c rxyq <br /> Total Number of Tanks 4 Total Fee Due - --;24J AN S 1 1986 1`�VI� <br /> ENV1RLWEviTAL HEALTH <br /> FERW/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />