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10/20/20.00 11:35 20946!34 FIFTH FLOOR PAGE 04 <br />0, ft I : r'kdbLl(- mt:AL rH SERVICES-E�NVIRONMOAL HEALTH DIVISION <br />LINDERGAND STORAGE TANK PROGRAM FEE WORKSHEET <br />outr-5-,-v,o , <br />MA4k-e=� .0 13g - <br />FACILITY Abuk—ES5 <br />CITY ST <br />$500 PEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE =AA I TAKIle <br />in <br />TANK 10# <br />TANK 10#(s): <br />IN <br />MIKt /e-,4aV64&7- <br />.SITE PHONE <br />IP COD�E� ip OF TA <br />q63,71, <br />eAto - 70 ZO <br />IR <br />C <br />CIRCLE WORK TO BE DONE:lOsure Installation Z,P C,3"r <br />Repair .-etrofit <br />1995 1999 2000 <br />X(# tanks) X (# Of years applicable) <br />10 <br />'4TORYINACUPAPROGRAm --,tin ipanir r. <br />� $2611 TANK I #TANKS X S261 = <br />CLOSURE FEE = $261 / FACILITY I s <br />