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.... ._. _ <br /> UNDERGR,,.JND STORAGE TANK PROGRAN..,oEE WORKSHEET <br /> ,,(dr <br /> FACILITY NAME n FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 36-2-4 S • ktKPoRT-N/v <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> STt�c yI m rl CA '52-06 <br /> APPLICANT BILLING NAME a APPLICANT CONTACT NAME <br /> cM <br /> CDA+l) <br /> R ��1zTLF TE�HAI OL OCnl e775 rr�, IC04eL (V <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> IL'dF E.f7— L-Gr1 SVtrx- a0-1 a3 -Osl49 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S�('�CK--GPA) Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (S 170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#Is): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s); TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Consducdon Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$7121 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s): <br /> TANK LINING REPAIR FEE =$2671 TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$88 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK K I RECEIVED BY 10ATE RECEIYEO <br /> SR <br /> EH 23 032(REVISED 8-"1) <br />