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FEE WORKSHEET <br /> DOA _ / ' / � /V � �- <br /> ADDRESS f L IVO ���D LQC fG'�"GP✓ �jS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. 50,0z) <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 /> Tompoii ary Closure (peg" tank' Underground ound Stor age TanN 1 i1 4v ti lf.r€ <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 r Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <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 $150 <br /> b. 3 Additional Tanks x $50 15O <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 /> 12/85 4 4 <br />