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FEE WORKSHEET � I <br /> DBA lV GW Ropc L Ak)Dlg16 <br /> ADDRESS -1'-() . /.3ox 1117 )3`q5 W. WALNUT- TNo,?A/ u,-Jj CA . 9W '� <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 50 00 <br /> b. Additional Tanks (#�_ Additional Tanks x $50) 50 m <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) 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) <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 L Total Fee Due 3 a t0 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank 11(�(y�(�M�� <br /> b. 3 Additional Tanks x $50 I1INNii�'JJ`''1144�d��, tliiaawllJ/ <br /> 2. State Surcharge, 4 Tanks x $56 AN 3 1 198b <br /> Total Number of Tanks 4 Total Fee DUXNV"EMTAL HEALTH <br /> PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />