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' unuL unu ��UKIIUL InnA rKUUKnn - ILL muKhSMLI C � . <br /> A FACILITY/SITE NAME /,' ,:� <br /> (° FACILITY CONTACT NAME <br /> I { 7� �c <br /> L STREET ADDRESS <br /> Tr`US, ��K SITE PHONE 1 WITH KNCK canm <br /> Y CITY <br /> c STAT ZIP CODE t of Tanks <br /> { at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L C 1� <br /> 1 MAILING ADDRESS APPLICANT PHONE t <br /> A ��, ��21 wirN AMC. cane <br /> N CITY <br /> I STAT ZIP CODE TYPE of APPLICATION <br /> GLOwU11E. IN9T�LL�T�ON. ITC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 2011 <br /> 1907 1988 1989 <br /> V A \OCD \ D(D f 3CSU <br /> E TANK FEE = $50.00 each TANK <br /> F f Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply (-by fee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see C <br /> I A HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks -L x $56.00 1986 1981 1988 <br /> Y (enter imount and year) 1989 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S 1 Tanks___ x $90.00 f <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> I Tanksx $80.00 PA <br /> P PLAN CHECK (Installation or Repair) <br /> l <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f '— <br /> REPAIR <br /> MITISERVI ES <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E t Tanks x 1110.00 $ <br /> P ...... — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one how to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) <br /> (when applicable) <br /> FEE = $30.00/hr FEE _ $35.00/hr <br /> FEE = 135.00/hr $ � <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 5B 55 <br /> • <br />