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E FACILITY ADDRESS <br />L <br />CITY <br />P <br />P APPLICANT/BILLING NAME <br />L <br />'E'i _Vj <br />C MAILING ADDRESS <br />A <br />r <br />T CITY <br />'S (Nn ScS� <br />I SITE PHONE " wi:h AREA =1' <br />C,4 <br />- 1311 <br />STATE ZIP CODE # of TANKS <br />at SIT' -3 <br />APPLICANT CONTACT NAME <br />Yef Ems 7,1 -1c- —.f Wr-N ii'S <br />APPLICANT PNONE S UITR AREA CODE <br />'7 ). D44 <br />STATE Z i P CODE TYPE Of APPLICATION <br />q51) a <br />(Closure, trazsttacia,, etc.)`�1 rte_ <br />TfWA1 <br />C! <br />L <br />PERMANExT CLOSURE (Removal or AuthoriZed Ciosure-in-Place) ! <br />TAMC I.D. 6(s) <br />0CL9SURE <br />FEE - 573.00/hour (3 hours minimus/TANK) <br />I <br />Jr TANK(S)X SZ34.00 o <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Alan Review L Inspections) I <br />TANK I-0. #(S) <br />R <br />E <br />TVIPOWY CLOSURE FEE = 576.00/hour (3 hours minimWFACILITY) ! <br />S23&.00 siniaw <br />S <br />P <br />INSTALLATION PIAN CNECK (Plan Review L Construction inspections) <br />TANK I.D. x(s) <br />L <br />A <br />N <br />PLAN CBECK FEE 2 578.00/hw' CS hours miniwus(FACILITY) <br />• $624.00 minimum <br />; <br />R <br />REPAIR FIE (Workplan Review L Construction inspections) <br />TANK I.D. "s) <br />E <br />P <br />TANK LINING REPAIR FIM ! $73.00/hour (3 hours minimWTANK) <br />! TANK(s) X SM : <br />t <br />A <br />-00 <br />I <br />TANK RETROFIT REPAIR FEE = SM.00/hour (3 hours win./FACILITY) <br />x )x(.,00 minimumS <br />R <br />PIPING REPAIR FEE s S73-00/hour (3 hours miniaWFACILITY) <br />• S73A.00 minissam <br />! <br />N <br />TRANSFER FEE = Sm.00 ( UNAUTHORIZED RVJASE EVALUATION z SM.00/hr IYy1cm <br />{ <br />S <br />C( CONSULTATION FEE s S75.00/hr I I SAWLING INSPECTION FEE s $75.00/hr S <br />TOTAL <br />FOR OFFICE USE ORY l <br />-� <br />SUEEf►S Y COMPUTER ! I LOC CDOE i DIST CODE IAPONT RECEIVED 1 CHECK WCASN RECEIVED BY i SDATE RECEItEO <br />IT - <br />