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co <br />FEE WORKSHEET <br />DBA E-A SE2�/E aZC30 �Ni2►Ss 1 A,A <br />ADDRESS �3 S . ��-FX, {r 4,, r� i 5� , �, , t n • <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />..., <br />b. Additional Tanks (#_,?_ Additional Tanks x $50) <br />ISO <br />2. State Surcharge <br />9 (per tank) (Due with Permit Application, <br />0 <br />on renewal or amendment of operation permit) <br />($56 x Total #�_ Tanks) <br />3. *Temporary Closure (per tank) Underground Storage Tank in <br />•-hich <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 $g0) <br />Total Number of Tanks ?t�j g <br />Total Fee Due <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />with your check <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 <br />b. 3 Additional Tanks x $50 <br />2. State Surcharge, 4 Tanks x $56 <br />*Both closu <br />12/85 <br />Total Number of Tanks 4 <br />will be conditioned. Cor <br />0 <br />Total Fee Due <br />t a Health District <br />of <br />$150 <br />150 <br />$ c�[gaylzl <br />FEB 18 t986 <br />ENVIROMENTAL HEALTH <br />senf#1tMrtrJecovv .� <br />