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y r ' <br />41 <br />€s <br />FEE WORKSHEET'° " • .a� <br />DBA �,'fi�`'•`� J� �. i <br />ADDRESS "'1`AhJ�.�'Y �J ►J ;. <br />1. Opera-ing Permit Application/Annual Inspection Fee <br />a. Existing Facility and lst Tank @ $150. 1U` <br />b. Addit onal Tanks (# 3 Additional Tanks'x $50) <br />2. State Surcharge (per tank) (Due with Permit Application, <br />& <br />on renewal or amendment of operation permit) y„ k <br />1 <br />(QrF v Tntal# Tnnlrc - d <br />. n. <br />3. *Temporary ;Closure (per tank) Underground Storage Tarek in which A, <br />"storage has,ceased but where the owner/operator proposes to <br />I <br />re�Use tank within 2y ears. 'N49 <br />(# Temporary closures x $80) <br />4. *Permanent Closure (per tank) Underground Stora Tank in which s ' <br />storage has ceased and where the owner/ope,r ; or ha no intent - 5 <br />3 { <br />of re -using tank within next 2 years.-'�p'c� <br />e ( Permanent Closures x $90) <br />1 Number f Tank` a1 Fe D e. <br />Tota m o T14anks <br />Make all fees h Dis rict. nclose.this worksheet <br />payable to San Joaquin Local He <br />with your check and the completed application <br />t <br />EXAMPLE,- Annual Fee for Facility with 4 Tanks <br />(1) regular, 1 unheaded, 1 supreme, <br />la. Existing Facility & 1st Tank <br />b. 3 Additional Tanks x $50 <br />2. State Surcharge, 4 Tanks x $56 <br />Total Number of Tanks 4 Total Fee Due $524 <br />-- v .. <br />*Both closures will be conditioned. Contact a Health Qistri ,95ZI�tiKif-ciFoPT OF GOODS <br />12/85 <br />