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FI <br />FACILITY SITE NAME FACILITY CONTACT <br />E FACILITY ADDRESS SITE PHONE # with AREA CODE <br />i <br />CITY STATE ZIP CODE# of TANKS <br />A at SITE <br />P <br />P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />L <br />I <br />C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />A <br />NSTATEF, <br />E ZIP CODE TYPE of APPLICATION <br />T CITY <br />(Closure, Installation, etc.) <br />Toru <br />C PERMANENT CLOSURE (Remsvat or Authorized Closure -in -Place) TANK I.D. #(s) <br />L <br />0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)__I_ X $234.00 = S Q <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum $ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />5 <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br />A g <br />I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />R $ <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimus <br />M TRANSFER FEE = 520.00 <br />I ---- <br />S — <br />C CONSULTATION FEE _ $78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # LOC CODE <br />EH 23 032 (REVISED 4-6-95) <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />DIST CODE AMOUNT RECEIVED CHECK #/CASH <br />S <br />g <br />TOTAL DUE S <br />:::::-.::-.:�..:::,sa_ :�:__:at�=—:::w. <br />RECEIVED BY DATE RECEIVED <br />