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0 <br />SAN JOAQUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVISION <br />UNWOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />T <br />FAM ITY SITE NAME <br />f rs <br />FACI TY CONTACT NA <br />AMOUNT RECEIVED <br />....:;....................;......._t..........................................................s..:. <br />......:............s:.s.s.¢ .....a:. <br />...:.......« :.........::::::s::.: <br />.... <br />CHECK #/CASH RECEIVED BY DATE RECEIVED <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /># TANK(s) X $234.00 = <br />$ <br />A <br />P <br />CITY <br />1 <br />STATE <br />ZIP CODE <br />(f <br /># of TANKS <br />at SITE <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />$ <br />P <br />APPLICANT/BILLING NAME <br />APPL ANT CONTACT NAM <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />C <br />A <br />MAILI G ADDR S <br />!/✓W kf6 V % <br />APPLICANT PHONE # WITH AREA CODE <br />12 <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br />I <br />V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />F (multiply # by fee for <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br />L <br />0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />AMOUNT RECEIVED <br />....:;....................;......._t..........................................................s..:. <br />......:............s:.s.s.¢ .....a:. <br />...:.......« :.........::::::s::.: <br />.... <br />CHECK #/CASH RECEIVED BY DATE RECEIVED <br />L <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />AMOUNT RECEIVED <br />....:;....................;......._t..........................................................s..:. <br />......:............s:.s.s.¢ .....a:. <br />...:.......« :.........::::::s::.: <br />.... <br />CHECK #/CASH RECEIVED BY DATE RECEIVED <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />$ <br />.2391.9-6 <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br />1 <br />S <br />C CONSULTATION FEE = $78.00/hr I SAMPLING INSPECTION FEE = $78.00/hr $ <br />TOTAL DUE 1 $ Z <br />FOR OFFICE USE ONLY <br />...................................................................... <br />.i <br />SWEEPS # <br />........................................................... <br />s::a............................................................................_.._........ <br />::t::.::es <br />COMPUTER # <br />.. <br />a:::a::a:s.............................................:::a <br />LOC CODE DIST CODE <br />AMOUNT RECEIVED <br />....:;....................;......._t..........................................................s..:. <br />......:............s:.s.s.¢ .....a:. <br />...:.......« :.........::::::s::.: <br />.... <br />CHECK #/CASH RECEIVED BY DATE RECEIVED <br />