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FEE WORKSHEET <br /> DBA <br /> _j) ' - <br /> ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee S e]r <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# <br /> Additional Tanks x $50) U " <br /> 2. State 'Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total # Tanks) <br /> + i°t,...........--._ /`� 1'w��..i �!i +-+u i i u .i t u i u���C T Ci i�n. 1 1 1 �V'!I S 1 c 1-1 <br /> J. jernporar lr lisui tFJCI LQlIh�' <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 --3Total 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 /> la. Existing Facility & Ist Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due <br /> JAN 2 8 � <br /> *Both closureswill be conditioned Contact a Health District Repres� TAL HEALTH <br /> — PERMIT/SERVICES <br /> 12/85 <br />