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' J1'�Ir Ii'aWNl�r l-u I.HL 1'1GML1n L1 Kill <br /> VVERGRGUNO STORAGE TANK PROGRAM - FEE WORKSHE?i' <br /> F FACILITYISITE NAME FACILITY CONTACT NAME <br /> A <br /> c a <br /> 1 <br /> L STREET ADDRESS c SI HONE 1 (with Area Code) <br /> T <br /> Y CITYTE IIP CODE 1 0l TANK'S <br /> j at Site <br /> PA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS AP I ANT PHON 1 (with Area Cade) C <br /> A S <br /> N CITY STATE ZIP CODE TYPE-o( APPLICATION <br /> T J osur , Installation, e <br /> FACILITY FEE - 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988 1989 <br /> I f <br /> V <br /> E TANK FEE • $50.00 each TANK <br /> F 1 Tanksx 150.00 1986 1987 1986 1989 <br /> A (multiply_l-by tee for <br /> 1 each year applicable) S <br /> STATE SURCHARGE • $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25187 for applicability) <br /> T 1 Tanks_____ x $56,00 1986 1987 1988 1989 <br /> Y (enter mount and year) <br /> t <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) <br /> S CLOSURE FEE : $90.00 each TANK 1 Tanks„� x $90.00 f <br /> U <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE a 180.00 each TANK ==I x $80.00 t <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N=CHECKrEE0.00 each SUBMISSION/RESUBMISSION 1 <br /> R REPAIR <br /> E TANK REPAIR FEE • 1110,00 each TANK, 1 Tanks x $110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION ,. SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE FEE : $35.00/hr FEE • $35.00/hr t <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> i <br /> I <br /> SWEEPS 1 COMP 1 LOC CODE D15T CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />