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FEE WORKSHEET PER EACH FAC]*Y <br /> OBA FACILITY <br /> ADDRESS <br /> MAILING AORE <br /> OSS" ! _ <br /> 1 • Operating Permit Application®Annnal Inspection Fee <br /> a, First Tank at .Facility @ $ISry< <br /> b, Additional Tanks (/ Additional Tanks x S50) <br /> 2• State Surcharge (per tank) (N)e With Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total N Tanks) <br /> "Temporary Closure <br /> (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 /> (1_ Temporary closures x S80) (See above 13 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 /> (d__ Permanent Closures x $90) <br /> 5. Plan Check Fee 530. PAYMENT <br /> RECEIVED <br /> MAY 3 1 198b <br /> Total Number of Tanks f <br /> HEALTH <br /> 5 <br /> � PERMIT'SERYKES —� <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, I unleaded, 1 supreme, 1 waste oxT <br /> la. Existing Facility 6 Ist Tank <br /> $1.50 <br /> b. 3 Additional Tanks x $50 <br /> 15p <br /> 2, State Surcharge 4 Tanks x $56 <br /> —� 2Z4 <br /> Total Number of Tanks 4 <br /> Total Fee Due 5524 <br /> 'Both closures <br /> will be conditioned, Contact a Health District Representative< <br />