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FEE WORKSHEET <br /> DBA <br /> ADDRESS <br /> 1. Operating Permit Application/Annual Ins e ion Fee <br /> a. Existing Facility and 1st Tank @ $1 0. <br /> i <br /> b. Additional Tanks (# Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total # Tanks) <br /> 3, *TPmnnrary C;.1nriira (nPr tank) Underground Stnrane Tank in hi h <br /> storage has ceased but where the owner/operator proposes t , <br /> re-use tank within 2 years. ,, r <br /> (# Temporary closures x $80) ,�-,� <br /> 4. *Permanent Closure (per tank) Underground Storage Tark�C in which <br /> storage has ceased and where the owner/operator had no intent <br /> C4 <br /> of re-using tank within nex`t.N,years. <br /> (# Permanent Closures x $90) <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health Dist ct:y_ Enclose this worksheet <br /> with your check <br /> EXAMPLE - Annual Fee for Facil1 ty with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> 1a. 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 $52 <br /> APN 21G <br /> *Both closures will be conditioned. Contt�,.ct a Health District Representp&g MENTAL HEALTH <br /> V ERM VT/SERVICES <br /> 12/85 <br />