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., _. <br /> so JOAtX1IN mAln PI>Bltc IIEA1.n SER51tES - EBYit3flpEATAl KFJ1LrN 0.. -CM <br /> INOERGMA10 STORAGE TANK PROORM - FEE 40RIMNE£T <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> i <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA COOP <br /> E7 2S . a0 `fro? - o0 4/�G7- <br /> CITY� G STATE ZIP <br /> CODE # of TANKS <br /> A iv CA at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L G <br /> ( <br /> fi <br /> CNAILING ADDRESS Of APPLICANT PHONE # LITH AREA CODE <br /> A <br /> N <br /> Y CITY If ,e_!FA) � STTAATE ZIP CODE�L TYPE of APPLICATION a.St-e <br /> -�LTftti� (Closure. Insta(latien, etc.) ' <br /> TOTAL <br /> 1986 1987 7458 1969 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1.991) = $100.00 <br /> A XXXX X)= XXXX X700 XXX% S XXXXX%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AOp(icab(e) XXX% XXXX J XXXX f00(X K%)0( S KXXXXXXII <br /> 1 <br /> Y TANK FEE S50.DC/TANK (Prior to Janwry 1,1991) 5170/TAKX (After Tanury 1, 1991) <br /> E <br /> 0 Tanks 1987 1988 1989 1990 1991 1992 1993 19% 11995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX X1001 X)= S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX X)0(X Xb(X XXX% XXXX , I 5 <br /> L <br /> I STATE SURCHARGE FOR NEL FACILITIES ONLT = $18.50 'f <br /> T <br /> T # Tanks_ N 58.00 1988 Through 1990 (256) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 5 <br /> C PERMANENT CLOSURE (Removal "or AUThOrlled Closur#•in-PIaCE) TANK I.D. <br /> L <br /> 0 CLOSURE FEF 578.00/hour (3 hours minimum(TANK)� 1 ! f TANK(.) X S234.00 + 5 0 <br /> 5 Q <br /> U TEMPORARY CLOSURE (Plan Review 6 lrspectio s) TANK I.D. #(s) <br /> K <br /> E TEMPORARY CLOSURE FEE a 575.00/hour (3 hours minimmi/fAC(LITY) 923T..DO minimae S <br /> P1 INSTALLATION PLAN CHECK (Plan Reyiew S Construction Inswiciont) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CNECK FEE a S78.DO/hour (8 hours minimum/FACILITY) a 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review B CmKtruc;ion Inspection) TANK I.D_ #(s) <br /> E <br /> P TANK LINING REPAIR FEE - S U.00/hour (3 hours mini=AVTANK) N TANK(s) X 5234.00 a S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY) = 5234.00 minimuo S <br /> R <br /> PIPING REPAIR FEE = 578.00/have (3 hours mi nimae/FACI LITT) = 2734.00 mini imam 5 <br /> N TRANSFER FEE 520.00 � UNAUTHORIZED RELEASE EVALUATION = 178.00/hr S <br /> [ I <br /> S <br /> C CONSULTATION ISE = 578.00/hr I SAMPLING INSPECTION FEE • 578.00/hr I 5 <br /> ,B f}C K -F4eX s, Ar �/} ISO D !A/114L 071 R 11f I T Stk TOTAL DUE S DO <br /> FOR OFFICE USE ONLY <br /> SLEEPS # COMPUTER 0 I LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/GSH RECEIVED BY I DATE RECEIVED s <br /> EN 23 032 (REVISED 5-27-97) <br />