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i Attach To Check <br /> FEE WORKSHEET <br /> DBA Z7-/Se� <br /> ADDRESS RCX 6 STDCKionJ Cyj� 9520/ <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. /SO <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 /> ($56 x Total # ,. Tanks) f! <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 Z Total Fee Due _ <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet v" <br /> with your check and the completed application. ��y4 <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 S150 <br /> b. 3 Additional Tanks x $50 <br /> 2. State Surcharge, 4 Tanks x $56 �I 1t17781,- <br /> JAN28W <br /> Total Number of Tanks 4 Total Fee Due $524- k �9 <br /> ENVIROMENTAL HEALT <br /> PERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Represent e a�pG� ti <br /> 12/85 <br />