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FEE{ WORKSHEET PER EACH FACILITY <br /> FACILITY <br /> DSA _(�� -C tT }7yTy�4N ADDRESS <br /> MAILING ADDRESS I 3 I S Je/e s6 -a,') <br /> 1 S- 7 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility P $150. <br /> b. Additional Tanks (!cZ Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total M/ 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 /> �1�'femporary closures x $80) (See above N3 to, calculate surcharge) <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 , <br /> (// Permanent Closures x $90) y <br /> S. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, <br /> PAYMENT <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks RECEIVED <br /> ( 1 regular, 1 unleaded, 1 supreme, 1 waste oil ) ,JUN 81988 <br /> la. Existing Facility 8 1st Tank $150 $NIRONMENTALHMIM <br /> b. 3 Additional Tanks x $50 150 PERMITISERVIC@$ <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 /> 2-:56 <br /> ucI Z2 __ <br />