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FEE WORK-SHEET PER EACH FACILIlP <br /> i <br /> FACILITY <br /> OBA — C! <br /> ADDRESS <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ $ISO. <br /> b. Additional Tanks (N Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application. <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total M 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 /> (M Temporary closures x $80) (See above 13 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 . PAYMENT <br /> (� I Permanent Closures x $90} RECEIVED <br /> 5. Plan Check Fee $30. MAY 3 1 No. <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> Total Number of Tanks Total Fee Due C � <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 /> ( I regular, I unleaded. 1 supreme, I waste oil ) <br /> Ia. Existing Facility b Ist Tank 5150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $55 224 <br /> Total Number of Tanks 4 Total Fee Due $52.4 <br /> 'cloth closures will be conditioned. Contact a Health DistrictRepresentative. <br /> f v _ <br /> "+irl <br />