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� ^'V*- T L Cc.0 33 <br /> FEE WORKSHEET PER EACH FACILITY - <br /> FACILITY I <br /> DBA ';.� �_ - ADDRESS �3��s la d. Ar+ S -�c_C ri <br /> MAILING ADDRESS <br /> 1 . Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ 1150. <br /> b. Additional Tanks (I Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> PAYMENT <br /> on renewal or amendment of operation permit and temporary faam")I V E D <br /> (156 x Total N Tanks) MN( 1 ),J(,I <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in whit <br /> storage has ceased but where the owner/operator pr-oposegA60NMENTAL HEALTH <br /> PERMIT/SERVICES <br /> re-use tank within 2 years. <br /> 0— Temporary closures x $80) (See above f3 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 /> (I Permanent Closures x 190) �- <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks <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 a, t C <br /> (1 regular. 1 unleaded, 1 supreme. 1 waste oil ) <br /> Sp v <br /> Ia. Existing Facility b 1st Tank 1150 <br /> b. 3 Additional Tanks x 150 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 / Gss�y eumlml <br /> Total Number of Tanks 4 Total Fee Due $524 U1 <br /> PAYMENT <br /> RECEIVED <br /> 'Both closures will be conditioned. Contact a Health District Representat MAK 19 IJ81 <br /> ENVIRONMENTAL HEALTH <br /> -aG PERMIT/SERVICES <br />