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� t <br /> FSE `WORKSHEET PER EACH FACILI#' <br /> FACILITY, <br /> 09AADDRESS , <br /> MAILING ADDRESS <br /> I. Operating Permit application/Annual Inspection Fee <br /> a. First Tank at Faci 1 ity @ $150. l5" <br /> b. ' Additional Tanks (# Additional Tanks x $50) ! <br /> 2 State Surcharge (per tank) ('Due with Permit' Application, <br /> on renewal or amen nt of operation ,permit and temporary closure) <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), (See above #3 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., <br /> PAYMENT <br /> 0 Permanent Closures x '$90} ItECEIVED <br /> 5. Plan Check Fee $36. NOV 101986 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT SEkVICES q?. o <br /> Total Number of Tanks Total Fee Due <br /> i <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> withec <br /> aur check. <br /> Y c <br /> EXAMPLE - Annual Fee for Facility with' 4 Tanks f <br /> (1 ,reguT;ar, 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, ,­ $524 <br /> *Toth closures will be conditioned. Contact a Health District Representative. <br /> 2 <br />