Laserfiche WebLink
PP_ J UAWL11 W LUI:AL HEALTH D 1'R Y CT <br />f DERGROUND STORAGE TANK PROGRAM - FEE WORKSL <br />FACILITY/SITE NAME FACILITY CONTACT NAME <br />y C� , <br />L STREET ADDRESS SIZE PHONE 1 WITH AAEA CODE <br />T <br />Y CITY c STAT ZIP CODE I 1 of Tanks <br />10__ 0at Site <br />A APPLICANT/BILLING NAME <br />P APPLICANT CONTACT NAME <br />P � c <br />L <br />I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br />A <br />N CITY <br />T e 1rq�1� \_ STAT ZIP CODE TYPE of APPLICATION <br />a- ,(\ �`�� \� CLIGHURE, INISTALLATION, ETC. <br />A - <br />FACILITY FEE 2 1100.00 each SITE ADDRESS per YEAR TOTAL <br />C <br />1 1906 1987 1988 1989 <br />1 <br />E TANK FEE _ $50.00 each TANK PAY M Ely <br />7 <br />F 1 Tanks � x $50.00 1986 EF_1988 1989 ��� L <br />A (Eultipry-(-by fee for <br />C each year applicable) " �q 9 9 <br />1 <br />1 STATE SURCHARGE = $5G.00 each. tlAGAI T I SAFETY CODE Sec 25287 for applicability) <br />T 1 Tanks �_ x $56.00 1 IIT/ ERVI 1988 1909 q c� <br />Y (enter mount and year) <br />C PERMANENT CLOSURE (Resoval or Closure -in -plate) <br />L _ <br />0 CLOSURE FEE = $90,00 each TANK 1 Tanksx $90.00 <br />U <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK I Tanks x $80.00 $ <br />P PLAN CHECK (Installation or Repair) <br />L <br />A <br />N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 <br />P -- - _ $ <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, •iniEus one hour to be paid on plan subEittal) <br />I <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/h11, <br />f <br />TOTAL DUE $ (r� C ) Q <br />OFFICE USE ONLY _ o O (� <br />Im 9110111111111111 <br />SWEEPS I COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD C EC /CASH RCVD BY DATE RECEIVED PERMIT 1 <br />II��,M L <br />'' NYNY 'nI III$ INXI <br />..I' ! !..I MC ^U "q III I ; n � I �! ��'� ��Il�dl;�pilal!li!Ign101111n11111,tln—lftl�� <br />N) IIII!!HIIOm, tLAn 00unmn n d����!!!l�nn��.l� <br />0 <br />