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i <br />t <br />FEE WORKSHEET <br />�I <br />ADDRESS <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />b. Additional Tanks (# 3 Additional Tanks x $50) <br />2. State Surcharge (per tank) (Due with Permit Application, <br />on renewal or amendment of operation permit) <br />(t;6 y Total #Ta^ks ) <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 <br />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 />Ia. Existing Facility & 1st Tank <br />b. 3 Additional Tanks x $50 <br />2. State Surcharge, 4 Tanks x $56 <br />Total Number of Tanks -4 <br />Total Fee Due <br />00 <br />S�— <br />$ LW, <br />1 [AAR 41986 <br />224 <br />�0'0ENTAL HEALTH <br />$ 5 24F ERI IT/SERVICES <br />*Both closures will be conditioned. Contact a Health District Representative. <br />12/85 <br />