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L= GEN s-r -71 <br /> FEE WORKSHEET . <br /> DBA �.. � <br /> ADDRESS _ 31 '7} i-.[� r_ �'-G� 95 �3 1 <br /> 1. Operating Permit Application/Annual Inspection Fee ot <br /> a. Existing Facility and 1st Tank @ $150. [5o. <br /> �o <br /> b. Additional Tanks (# �1, Additional Tanks x $50) ID O <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total # 3 Tanks ) I(o <br /> 3. *T^ Clu-surc 1pe } I 1 IlnriarnrCupd Storana Tank which <br /> r�m pvrury �. va ui �Ncr c�ii�j - .., . <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 $40) <br /> Total Number of Tanks Total Fee DueI�,� <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check <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 $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. J A N 2 1 I $� <br /> ENVIROMENTAL HEALTH <br /> 12/85 FERMIT/SERVICES <br />