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FEE ta0 <br /> RK•SHLET PER EAU FAC Y <br /> OSA I"AC 1 L 1 TYF. ` <br /> r ADdRE$S a 011 <br /> , <br /> MAILING ADDRESS--. <br /> 4 X, '9 �'I� <br /> I. Operating Permit App)!CA tion/AnnuaV-1 nsecor� l"ee � d Sic <br /> am First Tank at Facility qq a { <br /> b. Additional Tanks (I Additbnal Tanks x $50) <br /> 2- State Surchar a ..`. , <br /> 9 {per tank) {due with Permit Application, <br /> on renewal or amendment of operation permit and temporary Josu <br /> {SSb x Total M Tanks) re) <br /> 3 'Temporary CIostere 4 <br /> (per an 'Un a"rground' ;torar�e Tank in which <br /> storage„ has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> {I� Temporary closures x $80) (See above-13 to calculaLe .surcha <br /> 4, "permanent Closure (per tank): Underg raund Stora e T n rge) <br /> storage has ceased and where owner/operatora k �n which <br /> the <br /> g has no intent <br /> - of re-using tanks <br /> PAYMENT <br /> (I Permanent Closures x $90) RECEIVED <br /> S. Pian Check Fee $30. <br /> ENVIRONMENTAL HEALTH <br /> Total Number of Tanks PERMITISERVICES <br /> Total Fee Due ; <br /> r <br /> Make all fees payable to San Joaquin Local Healtn District. Enclose this worksheet <br /> with your check r <br /> ON 40 <br /> EXAMPLE _ .Annual Fee for Fa V <br /> ciiity with 4 Tanks <br /> ( ! regular, I unleaded, l supreme. 1 waste oil ) <br /> 1 d <br /> la- Existing Facility b Ist Tank <br /> bo 3 Additional Tanks x SS0 a <br /> 1�0 <br /> z- State Surcharge, 4 Tanks x b56 <br /> 224 <br /> Total Number of Tanks 4 <br /> �. Total Fee Due S574 <br /> 'Both ,closures will be conditioned. Contact a Health [listric[ R <br /> t � _ epresentative. <br />