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I <br /> FEE WORKSHEET <br /> DBA " ' <br /> ADDRESS 1 i a� �r , — � / �-w'J <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $50) z <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) 0 <br /> I FFj x- Total # -Tanks 1 rk <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 /> Total Number of Tanks / Total Fee Due �- <br /> -�a <br /> a0b• O4 ` <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> withyour check and the completed application, rQGt�V14 ( „Sp •OO <br /> ba l st"Cr <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> - - -j pug S& v <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Sank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 D Lily <br /> 24 <br /> JAN 2 810 JAN 17 i086 <br /> *Both closures will be conditioned. Contact a Health District Re resentative. <br /> 01r,ENTAL HEALTH <br /> 12/85 <br /> HRMIT/SERVICES F ERMIT/SERVICES,, <br /> � <br />