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UNOERGAmm STORAGE LANK PROe(AN - FEE WiRKSNEET . <br /> t ENAME FACILITY CON] F"CAME <br /> T ' <br /> --SDR U -7'J <br /> f.ICITr ADDRESS S�^ITEPNONE N with AREA CODE <br /> to Q <br /> y �g Z l <br /> r WAIN ZIP CODE it!( 1E <br /> r NK5 <br /> 1, S ��J 9s <br /> APrLIr. Nt/OjLLINO NAME APPL ICAN�T/'C0111At"AM1 <br /> L /' <br /> I - PPLI NT PE MEA CODE <br /> C ( ILIHG AD S <br /> A <br /> NN �"b SME ZIP CODE TYPE of APPLICATION _, r� <br /> r,ltY ..\\ (C(6fura, Installation, etc J (/H+. <br /> N TOTAL <br /> — 1986 1081 196E 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • 1100.00 ! <br /> A <br /> O <br /> F FACILITY PENALTY FEES ASSESSED (If Applleable) <br /> I _. 5110/LANK Wtaf JanuAry 1, 1991) <br /> V TANK FEE 1SO.00/TANK (Prior to January 10991) <br /> E1986 1987 1988 19A9 1990 1991 1992 1993 1094 109S 1996 <br /> Y TankS <br /> F (multiply a try fee for 4 <br /> A ench year applicable) <br /> C A s <br /> 1 TANK PENALTY FEES ASSESSED xxxx X%XX <br /> I _. <br /> I STATE SURCHARGE + 156.00 each TANK (DUO Overt' S yearf) !OO Catl}etn1A M 6 ! Ends, ! <br /> Y a Tanks x SS6.00 1986 through 1990 1991 t9F 6 <br /> (Enter amount ed ynr)i (�/ �� ✓Qq ! <br /> C PERMANENT CLOSURE (Removal or Authorited Closure-I64(ACO) TANK I.D. NU) ^ <br /> L — VTANK) N CANKW__� X 5234.80. a <br /> 0 CLOSURE FEE - 179.00/h our (3 hour* minloo <br /> S – YANK 1.6. N(1) 0/1j <br /> U TFMPORARY CLOSURE (Pled Review 1 (naPettidItA) <br /> R --"— N 1I !234.00 • 5 Q <br /> E TEMPORARY CLOSURE FEE w !78.00/hour (3 houfa minIMILMI/tANK) 1ANK(A)�., <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inipettlone) LANK 1.0. N(s) <br /> A • !624.00 m(nlosm 1 <br /> N PLAN CHECK FEE , 178.00/hour (8 have minimm/FACILItY) <br /> R REPAIR FEE (Workplan Review 5 CohatfuetIbA 1 soctioRf) tANlt t.D, N(f) <br /> E --- • s <br /> P TANK LINING REPAIR FEE • !78.00/heur (I hoursmininAm/tANK) N tANK(f) X !234.00_� <br /> A - --- • 5234.00 Nihiftis 5 <br /> I TANK RETROFIT REPAIR FEE • 178.00/hour (3 hours min./FACILITY) <br /> R — 5234.00 mint Al 1 <br /> PIPING REPAIR FEE • 176.00/hour (3 hours minimum/fACiLItY) a <br /> -M TRANSFER FEE • SMOG UNAWRORIZED RELEASE EVALUATION • <br /> S _ <br /> c CONSULTATION FEE 178(00/hr SAMPLING INSPECTION FEE a s18.00/he <br /> TOTAL DUE <br /> ,R nrFILE USE ONLY <br /> 011 rt. RERIF .wf r wu w . : .: <br /> ;bFEPS q COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED HECK N SN RECEI DBT DATE RECEIVED i� <br /> m;awAT ,..;m RRarRAM <br /> . . _._........_....... <br /> FH ?S 032 (REVISED 11-1.92) /� I IT :l) Page 11 3 <br />