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FEE =1ORKSHLET PER EACH Wee <br /> FACILITY <br /> D[,A �,lz j' �o. Kik: . �p ADDRESS / ��6dP�iit 9�i/ oua ��✓ ��6/h�Cl7 <br /> MAILING ADDRESS <br /> PAY �`IVr — <br /> RECEIVED <br /> 1 . Operating Permit Application/Annual Inspection Fee �� 1 2 19dd <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (/ Additional Tanks x $50) ENVIpE MITI R ALTH <br /> VICES <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 # 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 /> (B_ Temporary closures x $80) (See above N3 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 /> (A' .>, Permanent Closures x $90) <br /> 5. Plan Check Fee $30. 36 . n n <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 /> n <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks / r <br /> ( 1 regular, I unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility 8 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 2-RG <br />