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FEE WORKSHEET <br />DBA <br />ADDRESS tz u2C a �c� A � S' � 0 C� 0 �-. , '�. q r;;- <br />1. Operating Permit Application/Annual Inspection Fee <br />a. Existing Facility and 1st Tank @ $150. <br />b. Additional Tanks (# _V,_ 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 # .3 Tanks) <br />-y r (� -� ) VtiuLl Q�'�i uilu JtVI agC TQtlk I ii WII'l l,ll <br />J. semi ur'ar Clusure 'per Laiik <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 __3 <br />Total Fee Due <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />with your check <br />EXAMPLE - Annual Fee for Facility with 4 Tanks <br />(1 regular, 1 unleaded, 1 supreme, 1 waste oil) <br />Ia. Existing Facility & lst Tank $150 <br />b. 3 Additional Tanks x $50 150 <br />/ Ea <br />I-eo © `^ <br />2. State Surcharge, 4 Tanks x $56 224 <br />Total Number of Tanks 4 Total Fee Due $ r aYTO <br />FEB 3 198b <br />*Both closures will be conditioned. Contact a Health District Repre <br />12/85 <br />HEALTH <br />