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FEE WORKSHEET
<br /> ,; ,DBA ��wENS i S
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<br /> ADDRESS rS. © G� L !CD _ e•,� '� �+ �C-/� ~•9.�374 -F�
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<br /> • �'�'r�•+•..:�,.i, __ ,:,S*t. `��,,. �T' ��.'��+{�:'�"• c '4'�..t�.+-�'F+.�.+s�,,h"�i4• I1+y"��-�SK r�,,,..{'y'.ij•
<br /> r .h�. - , •.{'h
<br /> .a Operat#ng Permit App]ication�'Annua] Inspection Fee r`
<br /> a. '`Existing Facility and 1st Tank @ $150 ,- '�
<br /> it
<br /> b. Addit#anal Tanks( d� Additiona] Tanks x X50) 71' 00
<br /> e 2. `State Surcharge (per tank) (Due with Permit Application,
<br /> .�. :. .• : ter, �� ��t � , • � .: � -;�,• ,.
<br /> ... amendment of operation perms
<br /> on renewal oramt) ""; ' "' r- sem-- ✓s, �y {,
<br /> ':-::'*Y. ($56 rota] Tanks)
<br /> +Yt, .:.7�ML7ti.l+''f
<br /> .�•3 *Temporary Closure - . a ;....a1; + � •�
<br /> �. •p y [per tank) Underground StorageTank in_which �'��"' ,'�:
<br /> storage has- ceased but where the owner/operator proposes to
<br /> xre-use tank within, 2 years.
<br /> � .'r .t �.. �• y} � 4. t. � � l � � ar y
<br /> c]osurs` ' Temporary e x $S©)
<br /> ,X4. *permanent Closure (per tank) Underground Storager
<br /> JTank� in whic
<br /> ..storage has ceased and where* the Owner/operator has no ;intent
<br /> 4 of re using tank within next 2 ears
<br /> � f 44fPermanent Closures x"$94)
<br /> cY%� �7. i(_+ ��:f+3y► �4. � r.r -y ? �s �wttr::> aic w'r .�: y'n.�r�Y ��* �v�r .�
<br /> 4 1 V.- •s'��..��.,.// ... rfc .r_ ,+x i i + f 3
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<br /> otos Numb �'1L��s�4' 7♦ + ,��y l� ���4 ,� s� 9�}9 '���.. Y r a1'_'�'` '�,=L�'�l�y h= -
<br /> ,. T er of Tanks
<br /> "Total Fee Due
<br /> +13�., - i rl3tiM-ii-4r Y .+ ;•2�ry ." 1-• �S" :.r r ,l' '1.. --•sr s.)4�'r `j" ! �''�'� f' _ ."aao:
<br /> y;:'.ten _ - l .q� _r w w {+�'i'• M 1 r, �' +c
<br /> Make aTl .r► a R rst�gf,i� yr» r f�r.�C
<br /> ees payable to San Joa uin Local Health District. =Enclose this wo'rksh'eet
<br /> with your_check and the completed� application. r�, � " ` �`�''�`s�./�+i• �Tb .��-.� J ;f y 'r �� • ���yw i �1
<br /> YT�i�+C� Ji.Y :i li�+y'7�73' �i���i i � -s r-_. L �4 i•F �+ir•,�•tyylJ.^s, 3`y.. >� f Y tlf•�i�}" -� •+(.xr"}-:i +..
<br /> �� '� "i,�,,.�.f' `��•:�f off ��r ..re++rr S_ �•s�.�,r #tuTi'+? E�?••".i: 1S r-"" �r ti f�l�ir't"r _a, x'
<br /> ?,r i ^ v ' u ,{r ;. ti r;t + �.r• r.I.. 4 Ya a,
<br /> i? •';}, f"•fr�4t.�+"� � 4 ��,�•. `+.{,. ,- t f �' .� L fe. .. `� '+4°�,'�'`' +1'[� ii.�n� '
<br /> .. EXAMPLE - Annual .Fee for Facility with 4 Tanks ' ' ••' �} �� ' ` `�' '`
<br /> �.- '' + r�l regular, 1 unleaded, 1 supreme .1 waste oil ) -
<br /> x -'-'- , - .,.. Via.- •.'� T•.f f _..�•j+��i,
<br /> a. Existing i•aci l i ty & int Tank -� ISOT-
<br /> ,-� 7e: '�• =`. :1 yr- ., , o �r fir. ' ' �Lk. r:i- ' 5r
<br /> b. t3 Additional Tanks x $50 a . 154
<br /> 4� =: "State Surcharge, 4 Tanks x $56 -A 224 ¢ . W, ` '�
<br /> CJ"ri'� '_' �.-i.;is -�� �- • •� + s. _ ''.}+w•i.Y�f,. ..��� • �.ri`�..1,,.•.•I
<br /> .. ' ..:'Total Number of Tanks 4
<br /> Total Fee Due $524 r• fi:- :, ' "
<br /> *Both `'� _ : -' . • '' _�" _ ' :.- -,.:=�..��' ^'�+`'
<br /> closures will 6e conditioned. Contact a Health
<br /> District
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