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FEE WORKSHEET PER EACH FACILIT% •• <br /> FACILITY <br /> DBA ADDRESS <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (f 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 NAL 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 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 /> (/ Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due "" —L <br /> �SS�D <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check . <br /> PAYMENT <br /> RECEIVED <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks AUG 2+1987 \ <br /> ( 1 regular, 1 unleaded, 1 supreme, 1 waste oil ) ENVIRONMENTAL HEALTH 1 <br /> la. Existing Facility b 1st Tank $150 PERMIT/SERVICES <br /> b. 3 Additional Tanks x $50 150 �1fn �d1J <br /> 2. State Surcharge, 4 Tanks x $S6 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> loth Closures will be conditioned. Contact a Health District Representative. <br /> :6 �Y <br />