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FEE WORKSHEET <br /> DBA —Aomf Amo <br /> -Zvc <br /> ADDRESS �- <br /> ----�_�9i.✓ iC/�9_ Off✓ � 95'.?.3 <br /> - <br /> 9s,2 s� <br /> I. Operating .Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $50) /.TD <br /> 2. State Surcharge (per tank <br /> ) (Due with Permit on renewal or amendment of operation permit)Application, <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 /> (#� <br /> Permanent Closures x $90) <br /> Total Number of Tanks _� <br /> Total Fee Due <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 & lst 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 <br /> _ Total .Fee Due '; <br /> ���N FES 3 �9�b <br /> *Both closures will be conditioned. Contact a Health District Represe t�� T/SEfMCEEWAL S TH <br /> 12/85 <br />