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FEE WORKSHEET <br />u <br />DBA 4// �4.�/a/7/!�U <br />ADDRESS I7 <br />1. <br />Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />ISO <br />b. Additional Tanks (#__17_ Additional Tanks x $50) <br />30 0 <br />2. <br />State Surcharge (per tank) (Due with Permit Application, <br />on renewal or am/er/ndment of operation permit) <br />$Lfr x Total # / Tanks) <br />—Y <br />3. <br />*Temporary Closure (per tank) Underground Storage Tank in <br />which <br />storage has ceased but where the owner/operator proposes <br />to <br />re -use tank within 2 years. <br />(# _ Temporary closures x $80) <br />4. <br />*Permanent Closure (per tank) Underground Storage Tank in <br />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 />104(# <br />Total Number of Tanks 17 Total Fee Due <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 <br />b. 3 Additional Tanks x $50 <br />2. State Surcharge, 4 Tanks x $56 <br />Total Number of Tanks 4 <br />Total Fee Due <br />VV <br />4198b <br />AVIROMEN-1AL HEALTH <br />FERMIT/SERVICES <br />*Both closures will be conditioned. Contact a Health District Representative. <br />12/85 <br />