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4r .-i <br /> FEE WORKSHEET , <br /> DBA %� Gf / ) i S / ja <br /> ADDRESS I IJ Elk (% (U D D 4 D �l f r %`S �' <br /> 1. Operating Permit Application/Annual Inspection Fee _ <br /> a. Existing Facility and 1st Tank @ $150. �cSD,Ud <br /> b. Additional Tanks (#_J_ Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> -. VtUl <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 aTotal Fee Duej 0 � O <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 /> 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 t �h � (E } <br /> e.� ( . <br /> JAN 2 4186 <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> ENVIROrJENUAL HEALTH-' <br /> F EWAIT/SERVICES <br /> 12/85 <br />