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FEE WORKSHEET <br /> DBA � ►1 <br /> ADDRESS I I4 CS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# ;L. Additional Tanks x $50) 100 . D O <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 w Total. � 3 TanI r ) � �/ <br /> �.y li n s V�.t: i i 11�i n�j i <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 <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 /> 4111.00 <br /> Total Number of Tanks .3 Total Fee Due/ "' �"'10,60 <br /> Make all fees payable to San Joauin Local Health District. Enclose this work heet <br /> with your check, and the completed application. <br /> EXAMPLE - Annual 'Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, l supreme, 1 waste oil ) <br /> la. Existing Facility & Ist Tank roraWto <br /> b. 3 Additional Tanks x 50 0 <br /> 2. State Surcharge, 4 Tanks x $56 JAN 3 U 1986 <br /> Total Number of Tanks 4 Total Fee Du , I MENTAL HEALTH <br /> MIUSERViCES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 0 <br />