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o"J% JUAwUIry LULAL HLALTH DIS1'RIC1' <br /> F FACILITY/SITE NAnE <br /> GROUND STORAGE TANK PROGRAM - FEE NORKSHE <br /> A. <br /> A FACILITY CONTACT NAME <br /> I /s/P/ �N <br /> a P_ �P/ rjtiC'P <br /> STREET ADD11E$3u <br /> T ' E �Q/N SITE PHONE 1 WITH .. eooc <br /> Y CITY ST T ZIP CODE 1 of Tanks <br /> o?C2S at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L od0-'r <br /> I MAILING ADDRESS <br /> C73 j n` — APPLICANT PHONE 1 WITH ARza c/olc. <br /> N CITY PP/9P2 E <br /> 1 Q" a) ST �ZIP�CODE cia.u.p P,P,iieALIDHaN. frc. <br /> AFACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> -- <br /> C TOTAL <br /> 1706 <br /> 1 1907 1908 1989 <br /> I <br /> V <br /> E TANK FEE _ $50.00 each TANK f <br /> f I Tanks z $50.00 1906 1981 <br /> A (sullipri- by lee for 1900 1909 <br /> C each year applicable) <br /> 1 L� $ <br /> L 51ATC SURCHARGE = 156,00 <br /> 1 A HEALTH L SAFETY CODE Sec 25207 for applicability) <br /> T 1 Tanksz t56.00 <br /> Y (enter Mount and year) RE 1907 I 1900 1719 <br /> t C?e7 <br /> C PERMANENT CLOSURE fReM4fip�Cail p {egL7{�rl� <br /> L <br /> 0 CLOSURE ra = 5 eac A <br /> S 1 Tanks z (90,00 S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one the for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $00.00 each TANK <br /> Tanks_ z $00.00 1 <br /> P <br /> L PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE = 170,00 each SUBMISSION/RESUDMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> P 1 Tanks _ z $110.00 S <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, <br /> I .ini.um one hour to be paid on plan sub.iltal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) FSAMPLING INSPECTION <br /> (when <br /> FEE =.$70.00/hr Iappli(able)EE = 175.00/hr <br /> fEC`$35, Whir If <br /> orrlCE USF oYLy TOTAL DUE 1 �i <br /> i <br /> SRC$ 1 OMP 1 LOC COD[ DIST CODE AMOUNT DUE AMOUNT REVD CHCC I/CASH RCUD BY DAZE RECEIVCOPER^ <br /> 32S f,h on MIT <br />