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v <br /> FEE WORKSHEET <br /> DBA 2 4 /a Lj ), A ) 1-)O C <br /> ADDRESS f d Isco X / / cc kE torC4 ��Q 5)'5-23 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> v� <br /> a. Existing Facility and 1st Tank @ $150. S <br /> b. Additional Tanks (#_L Additional Tanks x $50) <br /> State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of ooeratign oermit) <br /> ($56 x Total #_,,2- Tanks) <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 �� Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> 3 ( t • oa <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 /> 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 $5 gCr6U 1,/(j(�/�1�7 <br /> *Both closures will be conditioned. Contact a Health District Re rese iTisIn Tm <br /> IERM <br /> CES <br /> 12/85 ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES <br />