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FEE WORKSHEET PER EACH FACILA <br /> FACILITY <br /> PO <br /> UBA �e PC�li � C -L4( i � . ADDRESS � � ) C�?? /C 4- ,d6y- <br /> MAILING ADDRESS J/,A— `) <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ $ISO. <br /> b. Additional Tanks (/ 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 /> (S56 x Total X 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 /> (/_ Temporary closures x $80) (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 /> (1 ' Permanent Closures x $90) PAYMENT <br /> RECEIVED �lecl� 7�aj� <br /> 5. Plan Check Fee $30. SEP 9 - -) <br /> 1988 <br /> ll.IS c�Cur.��- CL17x O6c.ir/ I,. <br /> ENVIRONMENTAL HE LTH�j9 f* �GrK�I ! /' � <br /> PERMITJSERVICES� s u 7 I <br /> To[al Number of Tanks Total Fee Due / <br /> ' - � � <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. 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility b 1st Tank 5150 <br /> b. 3 Additional Tanks x S50 150 <br /> 2. State Surcharge. 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due 552.4 <br /> 'Doth closures will be conditioned. Contact a Health District Representative. <br /> 2-80 • 0 <br />