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FEE WO KSHEET, <br /> DBA PK S to e,-CF— <br /> ADDRESS <br /> ,-CF —ADDRESS ! 30 ( , Y9�es� 1J <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 1 <br /> b. Additional Tanks (# _ Additional Tanks x $50) -5 <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total - # a-- Tanks) �l <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 /> (#4— 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 2 Total Fee Due <br /> Vii_o 0 <br /> Make all fees payable to San Joaquin Local Health District Enclose this worksheet Q� <br /> with your check and the completed application. (ry(afS� <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks �� <br /> (l regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility & 1st Tank $1R 7 1986 <br /> b. 3 Additional Tanks x $50 ENW 60tVC TAL HEALTH <br /> 2. State Surcharge, 4 Tanks x $56 %4 , /6ErNICES <br /> Total Number of Tanks 4 Total Fee Due $ ltl <br /> FEB 14 lynu <br /> *Both closures will be conditioned. Contact a Health District RepftV*tti'VtjWjL HEALTH <br /> ICES <br /> 12/85 <br />