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r <br /> EE WORKSHEET <br /> BA a o <br /> )9,0 J3c> �S7 <br /> DDRESS J11 Crn S �►'�Gke <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility andilst Tank @ $150. SSUa <br /> b. Additional Tans (# Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or artrdment of operation permit) <br /> ($56 x Total , t Tanks)3..._ .. <br /> Under round <br /> 3. *Temporary Closure (per tank) Storage Tank in which 9 , <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. D <br /> Temporary closures x ,$80) <br /> 4. *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank within next "2 years. �O <br /> {$ / Permanent Closures x $90) <br /> Total Fee Dued� <br /> Total Number of Tanks <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) $150 <br /> la. Existing Facility & 1st Tank 150 <br /> b. 3 Additional Tanks x $50 224 <br /> 2. State Surcharge, 4 Tanks x $56 (� 1� <br /> Total Fee Due $524 II lam• � <br /> Total Number of Tanks 4 JAN 2 3 tibi <br /> ENVIROMEvTAL HEALTH <br /> *Both closures will be conditioned. Contact a Health District resentati MIT/SERVICES <br /> 12/85 �{ "� Tucr ,,. <br />