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SO <br /> Ftf-WORKSHEET PER EACH FACT ITYL <br /> •'f, 1 <br /> DBA <br /> dl-.iti���3 SHmr�T �7-�- FACILITY <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. I <br /> b. Additional Tankt (f�_ Additional Tanks x. f50) r� <br /> 2. State', Surcharqe. (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and. temporary closure) <br /> � <br /> ($56 x' Total N ; Tanks) <br /> � <br /> 3. "Temporary Closure (per tank) Underground Storage- Yank. in which {{ <br /> storage has ceased but where 'the owner/operator 'proposes to I' <br /> re-use tank within 2 years. <br /> 0 Temporary closures x $80) (See above #3 to' calculate surcharge).. <br /> 4. `Permanent Closure ( <br /> per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator�-has no intent I <br /> r. <br /> of re=using tank.. . PAYMENT <br /> (N - . Permanent Closures x $90) RECEIVED �(Q� <br /> 5. P1 an Check Fee E30. DEC 13" 1:988° <br /> ENVIRONMENTAL HEALTH . <br /> g PERMIT/SERVICES <br /> Totals Number of Tanks Total Fee Due _LAG <br /> Make all .fees payable to San Joaquin Local Health District. Enclose -this worksheet <br /> with 'your' check. <br /> EXAMPLE - 'Annua'l Fee for Facility^.wi th 4 Tanks <br /> (I regular, I unleaded, �1 supreme. l waste oil ) <br /> Ia. Existing facility b Ist ,Tank $150j <br /> b. -3 Additional Tanks 'x $50r150 <br /> • 2. State Surcharge, 4 Tanks' x $56 224. <br /> Total Number of Tanks 4 " Total .Fee Due $524 h <br /> *Both closures will be conditioned. Contact-. a Health District Representative. <br />