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FW WORKSHEET PER EACH FACI`YY <br /> ^ <br /> FACILITY <br /> DBA NASN RpC7an vADDRESS1 (10VqC"TBI- <br /> MAILING <br /> MAILING 9S�aC <br /> ADDRESS C) o K {� 7 D'a 7oA Cif. 9 �2 O <br /> 1. New Facility or Ad <br /> a 88 _-- <br /> b. Additional Tanks (# Additional Tanks x $50) <br /> 2. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. REGuL-rr2 Gi9J TO , vd <br /> b. Additional Tanks (# / Additional Tanks x $50) 0y 6 f E L. SSG.vU <br /> 3. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and tempora_ry closure) <br /> ($56 x Total # Tanks) 2.• 00 <br /> 4. *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) (See above #3 to calculate surcharge) <br /> 5. *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 Total Fee Due l 2.d O <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 $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 conditioned Contact a Health District Representative. <br /> 1 2-86 <br />