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fCC WORKSHEET PER EACH FACILITY r <br /> FACILITY <br /> 08A �—�' � ,•�,- , ADDRESS i��` % /' .� 1c � :�� ��_'_�_ '��� <br /> c' <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (M 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 M 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 /> (I_ Temporary closures x $80) (See above f3 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 /> (I� Permanent Closures x S90) - <br /> j C <br /> 5. Plan Check Fee $30. <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, iy p� d 1�� 5 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> AUG 1 ,0'c57 <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) ENVIRUMENTAL HEALTH <br /> Ia. Existing Facility b lst Tank <br /> $150 FERMIT/SERVICES,, <br /> b. 3 Additional Tanks x $50 150 <br /> PAYMENT <br /> 2. State Surcharge, 4 Tanks x $56 224 RECEIVED <br /> Total Number of Tanks 4 Total Fee Due $524 AUG 19 1987 <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 2-RG • • <br />