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FSE WORKSHEET <br /> r= . <br /> DBA State of California/Dept. of Parks & Recreation/Carnegie S.V.R.A. <br /> ADDRESS P.O. Box 1105/18600 Corral Hollow Road, Tracy, CA 95376 <br /> PLEASE SM WITH W#jtn lr <br /> 1. Operating .Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 150 <br /> b.—Additional Tanks f# t Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total i'_2— Tanks) 132 <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) 0 <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 /> (# ?eet�;anerst CTosures x_1y0_) o <br /> Total Number of Tanks 2 Total Fee Due $312 <br /> ,cas: SM VMH w <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 /> Exist`.ng Facility & 1st ;Tank - $150 <br /> b. 3 Additional Tanks x $50 <br /> 2. State Surcharge, 4 Tanks x $56 N O f <br /> F <br /> Total Number of Tanks 4 Total Fee Due $52�B 1986 <br /> ' ENVIROMENTAL HEALTH 1 <br /> FERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative <br /> 12/85 ' <br />