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FEE WORKSHEET// / '_,__. <br /> DBA / C' Il IV,17 <br /> / / <br /> ADDRESS Jf:/D ( f �—/-zl y , G�Sa7 Ol <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. - ? <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) <br /> ($56 x Total # Tanks) <br /> 3. *Temporary Closure (per tank) !nderorniind 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) <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 within next 2 years. <br /> (# Permanent Closures x $90) <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 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) �mGR° <br /> la. Existing Facility & lst Tank $150 MAR 5 1980 <br /> b. 3 Additional Tanks x $50 15&1NVIRGMENTAL HEALTH <br /> 2. State Surcharge, 4 Tanks x $56 224 FERMIT/SERVICES <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> *Both closures will a conditioned. Contact a Health Distric Representative. <br /> 12/85 <br /> Y `� <br />