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<br /> 'FEE WORKSHEE'
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<br /> „,.,DBA - "� i v6N 5 $ r F.,,. .t. F n ,r:,�` *•. ..
<br /> r -•• . -nrt ., t•
<br /> •i �i,'-''} i'' :.i.1` n,. .al•iw.�•�riJ����•+ • •�'' � _ :�4�.,, 1�:.n'j't. 'L(.;' Y s �:t y,. `. •. -v�:rr ��r J f -r •��
<br /> ADORES 5 �`
<br /> ' 1
<br /> .. 7i'a,ry ..oma 7�* �: al•` � ;• pr r:c 'yt�& �l�k �-•rs'+r ?�s .,:.F...�,� �'��.,1.. i,t�••�„R„� y.
<br /> .le. :� kl°. -• y' *�" ' �.Y="r 4.�� r aw �F Y, s ,.•t Aey.+.1;��•,t�,_rr 1 f 4d1 .Gly
<br /> + y� �s � ..,trial. �^ `:'r"`=�+� _ r +i•.
<br /> Operating.Penait Application/Annual ins ection Fee
<br /> •t L F } r, ,�,�
<br /> -•''Exi stint�•-. .. _. -.. .. p. .+ � 1^ '���
<br /> ,-
<br /> 9,.F aci l i ty and 1st Tank @ $150. �ti�-.I � , ', ��: U
<br /> Additional Tanks ( �— Additional Tanks x $50)
<br /> State Surcharge (per tank) (Due with Permit Applicata
<br /> ice+. ti:^. r,;, :. ,:,c-'•�;w. .._.._,•.. . .. ,_.._. _ ... on t � r
<br /> orn trenewal _or�amendment of operation permitdp
<br /> )
<br /> \$J� x�Otal 'TdllkS 'Y .. '.� ar_ rT #� s ',r 4 ��a:�#'T'rr.t* t ;7r
<br /> 3
<br /> _,.�:�.-�,„z�»,�+✓{� .it'iii{�! .. ri ;. .• '• ..� ..,,. .. �+'t' �Jn '�`" .rte•°
<br /> 73. *Temporary Closure [per tank} Underground Storage' Tank l.n ch
<br /> storage
<br /> y,...a, , .... .
<br /> storage has- ceased but where the owner/operator proposes to r `"
<br /> J-Zo �a_ •r. �";"Y.' r.:,-.. . •- _
<br /> re-use tank withinyers
<br /> , 2 a
<br /> �i t 4 -
<br /> f �r i-.+• rr r��,].t I..�I... -. . ,. - .t s � � - . ,�R ++ " .•x 1 � th r ti-4 �. ~
<br /> /
<br /> .�, '14T
<br /> "�lll.y l 14Temporary •closures xa$80) , 'r• ti e.y"'r .�� •r .,x_ ,+ r-, 1 +'E iiw.
<br /> - ..�1{: ,.•j.. + F � •��7 � 14 • .+h4 ��t - �l{1 ^+�•�3�w�q�k+
<br /> ` 4 " rmanent C1 o ur
<br /> •♦ Pe Closure (per tank) Underground Storage Tank in �P. � �� YS..t•
<br /> storage+ has ceased and where thewner/ope
<br /> orator has no' intent
<br /> *. h -ff W•j tti�� iY.'�'+1 -.'
<br /> 4 of re-using tank within next 2 years
<br /> `� f.il•ii�^+, -•. -1•f -- °' p �'I•r a!^.r►.. Y - .+ s+.r'J-
<br /> V f* .,, „ ,ti• R`r �. .r r 'ye
<br /> ; ( ,Permanent Closures• ._ x:`$90) �,� -'' v ,��, - zE� ► , .�c
<br /> a.;+.F ww,: }y1 -.�..�• ► �.- I ? w+tS:eq"►1''''j 7^ e °�'t+r 7 � S `• ° '�
<br /> Sys i•� 4 �' �.�y �'d etas rt+yl x' w• v';1f�1 i' a �.t , rw; 4Tb ,.
<br /> � y. °3 •+. :y .. .� w .�6w x{'"^ �s r it-k 'i.4���1t
<br /> ��•, _ a,�;�e�Ikr �s.,t�,�,��!,�'}���, �_ � � 't �-..,t_ ,� �6„€v'j�`_l f,r.�,�1i �r•f' �r ct
<br /> f Total Number of Tanks },_ T • .�
<br /> Fee Due ` t �,,�
<br /> 'f*=►.',�+`a�•r ���5�� ' �t�W�+,.:rl� .s •1 1� W` `\„ s,ff,t, r� � i,f � � Y � t3 .•f„i. �t:4` 1 ' x4�. w^,:7�'-
<br /> Imo. ;i: .;}.•-' A.. 4r,.f-e MY s. . _ '� _ � � } � �'r
<br /> •�Sl4i�+,'�,'�.ti'=A _ e! � :".=+� ...,. � - _ :•.��- `°-_r .. . � - ti lt.�'b''. +ti 1'lJ-9! 1� 'L+ ,�-
<br /> Make 'aTl fee's payable to San Joaquin Local Health District. nclose this worksheet ' s
<br /> + -�.' —l�T'.: -r -rte:c- ._;.." . °t '•.: � -' ,•, i � -
<br /> withyour-Check-and the completed application.
<br /> S✓+{ t '^ ti�r y + r .� y y, :a i°j jg y s� S r f e �r�tr!' a x {
<br /> r• 'r�• .�- y , tai✓ l=i f �1 * ' ..r. •rlwah'1 y Y�yent, !r t t+ +; !- �; ?t+ C:.l:�+ rY+s`ri ti.r�' �:I i� 7
<br /> i T �'T_t�-+�'� `' � � '` 1y.[ E '_ �s., i 6 a.la •• '' --ter-'.:,” `� +�hri� � �Jf �l :}•.+�,
<br /> Annual - Fee for 'Facility with 4"_Tanks'
<br /> regular, 1 unleaded, 1 supreme; 1 waste oil ) {t •='� � t�;� ,
<br /> facility & Ist Tank,
<br /> . --.3 Additional Tanks x $50 1' '� -� "r 150 -�' 7'1• w �
<br /> r=�r ._;State Surcharge, 4 Tanks x $56 .� •rr '! a ! Y�4r�� • ' - ;b
<br /> r. r
<br /> i. _ _ � 224 ,_ '•
<br /> YA :Total Humber of Tanks 4 Total 'Fee Due $524Pr
<br /> *Both closures will be conditioned. Contact a Health District Representative
<br /> �ZZ/$5 '�:�.�[ �`r:Y��1 -w'. r4r f. +f,+•'" � r�ri,� ,yt.x*4'C�.rx'. s.Sik�y � rt ry�
<br /> /yN e. SJ �1f '.%,rr. s f.,;•� �d ] 7 l,•.+t .s'rS?'{�' , �
<br /> _iftC t.. 'k'4.1 K'}.•-�,-{f S, yCt a v 'S��•wt. '?��.:r �` :r+. b .z r � moi.:' '�'..�»
<br /> _ - Y. ice•♦ �i�..; ..^3. .oma .' - �.. - -'t J ` gt �F'�'i♦ . 7-:
<br /> �"' �x°Av R ..� � '}kik '�' �Y'r / ♦ ;
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