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FEE WORKSHEET <br /> DBA Hy,,R,N06--N I Y IQC U <br /> ADDRESS A C . YQ&6 M I -)Z-- AV6, (`)fl tti ) A ,�A S 3 3 � <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $50) , 6(� <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> /PCC.. T \ �� <br /> f&rc x iotai r _ Ttiii icS� —— V -/'1/1 <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in which V <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> (# Temporary closures x $80) (%'f <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 /> (#—A Permanent Closures x $90) <br /> Total Number of Tanks S Total Fee Due (b30,6 d <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check and the completed application. _ (� <br /> -,l <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks ) �` '� 7 1986 <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) EhviRC - ENTAL HEALTH <br /> la. Existing Facility & 1st Tank $159Rm1T/SERVICES <br /> b. 3 Additional Tanks x $50 <br /> 2. State Surcharge, 4 Tanks x $56 " - 4 <br /> —MAR 7 Ndo <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> ENVIROMENTAL HEALTH <br /> F ERMIT/SERV1Cc s <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />