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FEE WOR4SHEET PER EACH FACILIT 10 <br /> 0 FACILITY <br /> DBA 'y L ' ADDRESS J 1� VtZ <br /> MAILING ADDRESS <br /> T- <br /> 1 . Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. /IS 0 <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 and temporary closure) <br /> ($56 x Total # I Tanks) 53 <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) (See above #3 to calculate surcharge) <br /> 4. *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> PAYMEN'T <br /> of re-using tank . RECEIVED <br /> (# Permanent Closures x $90) <br /> NQv 1$ 1�' <br /> 5. Plan Check Fee $30. <br /> ,ENVIRONMENTAL H.A,TH <br /> PERMITISERVICL. <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San J22fluin Local Health District. Enclose t is worksheet _ <br /> with your check . <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular, 1 unleaded, I supreme, 1 waste oil ) <br /> la. Existing Facility R lst 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 /> 3oth closures will be conditioned. Contact a Health District Representative. <br /> 6 4 51 A '99C <br /> ;-T- r <br />