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T <br /> EI FACILITY ADORESS SITE PHM S ui-.h AREA CODE ^ <br /> I <br /> z177C)o "c-1 <br /> ! CITY STATE ZIP CODE s of TANKS <br /> PI \ \ �c- qct, at SITE GJ <br /> PI APPLICANT/BILLING NAME APPLICANT CONTACT MME <br /> 5 —kms <br /> C MAILING ADDRESS f APPLICANT PHONE S WITH AREA =E <br /> A I ten^ <br /> T CITYSTATE ZIP CODE ` TYPE of APPLICATION pr l.a,�—Ln <br /> 5 ClfnSoS� �151 )a I (clowr�, Installation. .ce.) ��-� _ <br /> TOTAL <br /> 1 1 ' IWR 1 1990 <br /> ANNUAL FACILITY FEE (prior to :anuiry, 1, 1941) � 5100.00 1986 1957 19E8 <br /> A X)= I 7000( 7000! I 7000( 7000( S 70000000( <br /> C <br /> T FACILITY PENALTY FEES ASSESSFD (If Aoplicsble) X)00( 7000( f xxxx X)001 X7Q0I S 700000(X7( <br /> 1 <br /> Vj TANK FEE s S50.00/TANK (Prior to January 1,1941) { SITU/TANK (After January 1, 1991) <br /> E <br /> R Tanks = 1987 1958 ` 1909 4 1990 11941 11992 1993 1994 1995 1996 1 1997 <br /> F (multiply 0 by fee for <br /> Al each year applicable) x)4Ix � Xxxx Xx70( 70001 Im= I I ( � , I � S <br /> C <br /> LI TANK PENALTY FEES ASSESSED X)00( I X)= ` X)= X)= IXX70< <br /> ' f <br /> I STATE SURCHARGE FOR NEW FACILITIES CULT = S18.50 {s <br /> T <br /> Y X Tanks x 58.00 1988 through 1990 (S56) 1941 through 1996 M6 1997 <br /> SURCHARGE FOR 1997 5 <br /> C1 PER7w7ENT CLOSURE (Reasnal or Authorized Closure-in-Place) I TANK I.D. s(s) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minim�a/TANK) 9 TANK(s) X SM4.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 InspeCtiam) I TANG I_D. *(3) <br /> R <br /> E TV410 RY CLOSURE FEE = 578.00/hour (3 hours minimAW FACILITY) SM,00 minims S <br /> P INSTALLATION PLAN CHECK (Plan Review i Construction Inspections) TANK I.D. s(s) <br /> L <br /> Al <br /> N, PLAN CHECK FEE 2 $78.00/how (5 hours Tini=AWFACILITY) 5624.00 miniauw s <br /> R REPAIR FEE (Workplan Review i Construction Inspections) r TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE a 578.00/hour (3 hours Mininta(TANK) t TANK(s) X 5234.00 : S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours Rin./FACILITY) a s234.00 Minima _ <br /> R <br /> PIPING REPAIR FEE s S75.00/hour (3 hours minioWFACILITY) • SM-00 Minimum S <br /> -M TRANSFER FEE = S20.00 i UNAUTHORIZED RELEASE EVALUATION = 575.00/hr YY ` - 3 <br /> S <br /> C CONSULTATION FEE = 375.00/hr I SAMPLING INSPECTION FEE a 578.00/hr <br /> TOTAL 011£ 5 cm <br /> FOR OFFICE USE ONLY / <br /> SWEEPS Y I CORPUTER 8 LOC COOS I DIST CiiE ! MIDIUNT RECEIVED I CHFrr wricw i vRrorvtn av Ic- <br />