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FEE'WORKSHEET <br />DBA <br />ADDRESS /j , <br />9 <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <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) <br />*r p .Y Cl(p tdnk) Und-,gr,,und ct Je which <br />v. Iem orae �osur c per Ora. c Tank i ti -Wi' �t <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 <br />Total Fee Due <br />A, <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />. <br />with your check <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 <br />b. 3 Additional Tanks x $50 <br />2. State Surcharge, 4 Tanks x $56 <br />Total Number of Tanks 4 <br />Total Fee Due <br />$150 <br />150 <br />224 <br />JAN 2 r3o <br />*Both closures will be conditioned. Contact a Health District Re re eNIRC}`ENTAL HEALTH <br />p &dam V4ERViCES <br />12/85 <br />lft� '"W <br />