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w <br /> FEE WORKSHEET <br /> DBA HAHM <br /> ADDRESS /0 '71 465- Yas EMS r� sfY , /lilfh4l7 ECAC C,4 95 3 36 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> t Tank @ 150. 1986 <br /> a. Existing Facility and is $ JAN 3 1 - <br /> b. Additional Tanks (# Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, �N�ryRp 1T/SEL HFALSH <br /> Surcharge �F>�autcES1r <br /> on renewal or amendment of operation permit) <br /> ($56 x Total # Tanks) <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 Y� L <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank within next 2 yeaprus,_ y �P� <br /> (# / Permanent Closu s x $ N7 <br /> Total Number of Tanks r Total Fee Due <br /> J �„�.vi•�-�P �' il�.o mac+-�� a�� �_, .�'z'cy�' � <br /> �4 ��e(��"yable <br /> 'a to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. �y�� ia►�'� <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 $50 150 <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 <br />