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FEE WORKSHEET <br /> DBA <br /> ADDRESS <br /> r <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. J <br /> b. Additional Tanks (#,� Additional Tanks x $50) � <br /> 2. State Surcharqe (per tank) (Due with Permit Application, <br /> on4 renewal or amendment of operation permit) (?(/ <br /> k :. T <br /> $5- otal ,3 Taf ks <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) —U <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 $90) _cam <br /> Total Number of Tanks 13 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, I unleaded, I supreme, I waste oil ) <br /> Ia. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 ISO <br /> 2. State Surcharge, 4 Tanks x $56 F241 CRY toTotal Number of Tanks 4 Total Fee Due1 <br /> EKVftMEsv1AL WEALTH <br /> FEtitJUSEA11iCES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 6 <br />