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FEE WORKSHEET p <br /> DBA /"(AT/�L s0/U f S�p <br /> '&71 EI //// <br /> ADDRESS /�Q(l p, 0_ OX 6D�8 ©AlOml C YZ52 <br /> l�i/YSicfl�) /oz . F wAg4Al z 6D(, �S2�o <br /> 1. Operating Permit Application/Annual Inspection Fee �c <br /> a. Existing Facility and 1st Tank @ $150. ASO <br /> b. Additional Tanks (#__, _ Additional Tanks x $50) JOU <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) / �J <br /> /CSF - T,.+el A ! Teak=1 _. _ /( G-. <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 <br /> with your check and the completed application. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 D c r <br /> 2. State Surcharge, 4 Tanks x $56 22 �I <br /> FEB 2 8 198b <br /> Total Number of Tanks 4 Total Fee Due $52ENVIROMENTAL <br /> LTH <br /> F ERMIT/SERV CES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />