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FEE WORKSHEET <br /> DBA rjE <br /> ADDRESS <br /> O p C=am <br /> 1• Operating Permit A <br /> pplication/Annual Inspection Fee <br /> a. Existing Facility -- --- -- <br /> and Ist Tank @ $150. <br /> Additional b. Additional Tanks (# '1-- c` <br /> tions] Tanks x $5D) <br /> 2. State Surcharge (per tank <br /> on renewal or amendment of operation Due with Permit Application, 1� <br /> ($56 x Total permit) <br /> 3. - Tanks) <br /> •r.. J' Clcs;.'re <br /> r- `;`�) llrtrlr�rnrni-in� Ctnr?na <br /> storage has ceased but where the <br /> owner/operator Tank i„ <br /> years, <br /> re-use tank within 2 p ator proposes to <br /> ( Temporary closures x $80) <br /> 4. *Permanent Closure (per tank) Underground Storage Tank in <br /> storage has ceased and where the owner/operator has tent <br /> of re-using tank within next 2 years. no intent <br /> ( Permanent Closures x $90) <br /> Total Number of Tanks <br /> ------- Tata] 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 <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & lst Tank <br /> b• 3 Additional Tanks x $50 $150 <br /> 2. State Surcharge, 4 Tanks x $56 15O <br /> Total Number of Tanks 4 Tota] Fee Due $5 <br /> FEB 25 ludO <br /> NITAL HE <br /> *Boni closures will be conditioned, Contact a Health District Represen�t�attye;1r-1/ RVCE5;H <br /> ---—�: <br /> 12/85 <br />