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S <br />I <br />T <br />E <br />b <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />SAN JQAOUINEE PUBLIC HEALTH SERVICES - ENVIRONMENTAL DIVSION <br />UNOtRGROUND STORAGE TANK PROGRAM - FWORKSH <br />FACILITY NAME I hA61LI I I 60MIA69 mmmm <br />Y pSITE <br />V b !_.A 1.— S .. &. . is eav <br />Iv <br />FACILITY ADDRESS SIVE PHONE With AREA CODE <br />1 -13 -1 3 3 <br />2 --lo) V-4 ►V1442-4-_ 1-a "03 . C 2A� _ <br />CITY <br />I <br />STATE <br />ZIPCODE » of TANKS <br />SITE <br />f <br />`&-16 �L C?1v <br />G/�I <br />d:ri)s2 1 qI at <br />IAPPLICANT/BILLING NAME I APPLICANT CONTACT NAME <br />MAILING ADDRESS <br />f APPLICANT PHONE » WITH AREA CODE <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) , <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />CITY <br />I <br />I <br />(Closure, Installation, etc.) <br />TOTAL <br />CI <br />PERMANENT CLOSURE (eemovai or Authorized Closure -in -Place) I <br />TANK I.O. +(s) <br />L'! <br />01 <br />CLOSURE FEE 578.00/hour (3 hours minimum/TANK) <br />TANK(s) X $234.00 - <br />S <br />S' <br />U1 <br />TEMPORARY CLOSURE (Plan Review b Inspections) i <br />TANK I.O. »(s) <br />R°5234.00 <br />B EI <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) , <br />minimum <br />mi <br />15 <br />Pi <br />INSTALLATION PLAN CHECK (Plan Review b Construction Inspections)I <br />TANK I.D. »(S) <br />L <br />A <br />NJ <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= S624.00 minimum <br />S <br />R, <br />REPAIR FEE (Workplan Review b Construction Inspections) <br />TANK I.D. :(S) <br />F <br />P! <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br />» TANK(s) X $234.00 = <br />S 2. <br />A <br />I;. <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />$ <br />M, <br />I <br />TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr ( I <br />� � <br />S <br />S <br />C <br />CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE <br />= S78.00/hr <br />� S <br />TOTAL DUE <br />FOR OFFICE USE ONLYr <br />_.. <br />SWE"cPSy» I COMPUTER » ` LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK W CASH ! RECEIVED 3Y I GATE RECEIVED <br />1 ► I I S I I - - - --.. ---- .__........ _. <br />cH 23 032 (REVISED 4.29-94) <br />