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ADDRESS <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />b. Additional Tanks (# 2 Additional Tanks x $50) <br />2. State Surcharge (per tank) (Due with Permit Application, <br />on renewal or amendment of operation permit) <br />($56Y Total # Tuser-nk- - \ <br />yy, .) � <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 />(# Permanent Closures x $90) <br />Total Number of Tanks C3 <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 & 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 />*Both closures will be <br />12/85 <br />Val <br />_ U <br />conditioned. Contact a Health DistricttRepresentati e. JAN 23 4�i3b <br />r <br />gNV1ROME.NTAL HEALTH <br />f ERMiT/SERVIC£S - <br />4 <br />