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4 40 <br /> FEE WORKSHEET <br /> DBAG'/F1G l�'A.S 4` r�.rCTit�✓G s� � 7GK�' '��L��' T <br /> ADDRESS',y04D W�c + STtY_tL�r�•.�. CA_ Cl Sao <br /> M1WWj,)G , Po &x ci g o -r�,� �►� , C VA Cr s.2z <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank 9 $150. 50 <br /> b. Additional Tanks (# ;3 Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendTent of operation permit) , <br /> (t,r-,6 x Total #LlTvnLc ) <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 00 S(40 CA4lje reV111fs1= <br /> (# S; Permanent Closures x $90) <br /> Total Number of TanksTotal Fee Due <br /> l <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 /> Ia. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150° <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> 4v <br /> S LJ <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> 2 tits <br /> ENVIRQMEyTAL HEALTH <br /> FERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 0 0 <br />