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c/ <br /> FEE WORKSHEET fo S z <br /> DBA -HI—� GdF ��✓ P ✓ Vic C-- <br /> ADDRESS <br /> ADDRESS Pt <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. X-s_0 <br /> b. Additional Tanks (# )--- Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) / <br /> ($56 x Total #_,'�_ Tanks) /(o <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 /> i O o <br /> Total Number of Tanks <-? Total Fee Due � <br /> Y <br /> Make all fees payable to San Joaquin Local Health -District. Enclose this worksheet <br /> with your check and the completed application. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank $1 ������Q <br /> b. 3 Additional Tanks x $50 1 <br /> 2. State Surcharge, 4 Tanks x $56 2 MAR 2 4 198b <br /> Total Number of Tanks 4 Total Fee Due $5NVIROMENTAL HEALTH <br /> fERMIT/SERVICES <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />