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i <br /> FEE WORKSHEET <br /> DBA cc, <br /> U <br /> ADDRESS 116 a;Z S,et" '01{, _ , j rml j 9S3z0 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. v- <br /> b. Additional Tanks (# Additional Tanks x $50 V <br /> 2. State Surcharge (per tank) (Due with Permit Applica <br /> on renewal or amendment of operation permit) <br /> ($56 x Tota i # Tanks) <br /> 3. *Temporary Closure (per tank) Underground Storage Tar <br /> storage has ceased but where the owner/operator pror <br /> re-use tank within 2 years. <br /> (#_ Temporary closures x $80) <br /> 4. *Permanent Closure (per tank) Underground Storage Tar__. ... ...... <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank within next 2 years. No <br /> (#_ Permanent Closures x $90) <br /> Total Number of Tanks -- Q— Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. <br /> Tank removed Jan 1G 1985 <br /> repord to Sacramento Jan 15th 1985 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. 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 $524 <br /> *Both closures will be conditioned. Contact a He l h District D-­p JAN ` <br /> 12/85 �A„ ic� ENVIhUiv L , IAL HEALTH <br /> �' FERMI?/SERVICES <br />