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FEE WORKSHEET <br /> DBA (-1'6.rr 71 7;Q 4 -,o !ci Al-- <br /> ADDRESS <br /> ✓GADDRESS �.3 6 .S .j b R aKc <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> ..i OD <br /> a. Existing Facility and 1st Tank @ $150. /�O. <br /> b. Additional Tanks (# Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ftc6x T_tal y T_ \ <br /> 1{wi� IV1.al #�_ IQriL_n�) <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 pelf_ G 0 Total Fee Due l <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. Q�' <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 c alit <br /> JAN 2 a rtes <br /> *Both closures will be conditioned. Contact a Health District Re rfd!ilttRfllgEr�kT hffl TH <br /> RhNOT RVICES <br /> 12/85 <br />