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�AiA/g �D <br /> FEE WORKSHEET PER EACH FACILITY • � � <br /> FACILITY <br /> ADDRESSS - <br /> MAILING ADDRESS 9L5 -�✓ �0 <br /> 1. Operating Permit Application/Annual Inspection Fee \ <br /> a. First Tank at Facility @ 5150. <br /> b. Additional Tanks (f 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 / 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) (See above N3 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 /> of re-using tank, <br /> (d- Permanent Closures x $90) <br /> 5. Plan Check Fee $30. —� <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, <br /> PAYMENT <br /> RECEIVED <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular, 1 unleaded, 1 supreme, 1 waste oil ) SEP 2 9 1988 <br /> Ia. Existing Facility 8 1st Tank WWRONMENTAL HEALTH <br /> b. 3 Additional Tanks x $50 150PERM'T/SERVICES <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 Health District Representative. <br /> EH 23 032 2/86 <br />