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FEE WORKSHEET / <br /> DBA C-1l ,C 1 J JIt e ! ery +,/l CC), <br /> ADDRESS _ //� �/ If <br /> JA�G,t�y c1 IdCf2nJ <br /> St74- . low TAn11C <br /> 1. Operating Permit Application///Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. ADD <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 /> 00 <br /> ($56 x Total # 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 Db. Dd <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 /> 416� 2. State Surcharge, 4 Tanks x $56 �(; ' <br /> IV <br /> Total Number of Tanks 4 Total Fee Due $ �Jtib <br /> FEB 2 I <br /> ENVIRCNIENTAL HEALTH <br /> *Both closures will be conditioned Contact a Health District RepresentFPIR/SERVICES <br /> 12/85 <br />