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14 <br /> FEE WORKSHEET <br /> DBA _r6XAC-0 W6. <br /> ADDRESS 4-4-0 WF-4,T &4A9,7-LF-4 WAY, 57- C K-M4 CA 9�5ZO6 <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) / 50 <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ($56 x Total #_ Tanks) 22LF <br /> J *Tn- orury rI r��v.n /-,r tan I,\ IInflArn�-minli C+nrano TUnL, �n .phi h <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> (# 0 Temporary closures x $80) O <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 /> (# 0 Permanent Closures x $90) 0 <br /> P8 <br /> Total Number of Tanks 4 _ Total Fee Due ul qk� 4 rj 24 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check n. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & lst Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks -4 Total Fee Due $524 <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> 12/85 <br />