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FEE WORKSHEET �/�,, n <br /> DBA 4)CTE2SO�V / � �l- 6• (...0 . <br /> ADDRESS 03 NAV Y <br /> 'arocm ro.j C q 9 z o <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $150. <br /> b. Additional Tanks (# Additional Tanks x $5D) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) <br /> ramex Total <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 lank in which <br /> storage has ceased and where the owner/operator hes no intent <br /> of re-using tank within next 2 years. <br /> (# I Permanent Closures x $90) <br /> _ ,y <br /> Total Number of Tanks 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 $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 ave <br /> O <br /> Total Number of Tanks 4 Total Fee Due $524 AR 71986 <br /> — MAR i 19�b <br /> ENVIROMENTAL HEALTH <br /> *Both closures will be conditioned. Contact a Health District Representatigi MIT/SERVICES <br /> 12/85 <br />