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Q"14 OAWL.11W LOCAL HEALTH DIOICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FA61LITY/SITE NAME <br /> A It A FACILITY CONTACT NAME <br /> C M 1_.. <br /> I L-1 <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> T I �) if <br /> Y CITY lfr& STATE ZIP CODE I of Tanks <br /> PrA,J <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> L <br /> I I C12 ELvitj Pfidhpsi <br /> I MAILING ADDRESS <br /> C APPLICOT PHONE I WITH AREA CODC <br /> Ev L2-) <br /> x CITY' TATE <br /> T E TYPE Of APPILCaLML— <br /> S ZIP CODS � I <br /> 4A Su CLGOU, ETC. <br /> 2 AC, C11TALLAT16 CI <br /> AlFACILITY FEE = $100-00 each SITE ADDRESS per YEA <br /> TOTAL <br /> E. L. PHILLIPS CONSULTING, INC. <br /> PHONE (602) 453-7802 <br /> P. O. BOX 1146 4538 <br /> LAKE HAVASU CITY, AZ 86403 <br /> <br /> e <br /> to t <br /> Poaryder o� <br /> $ <br /> Dollars <br /> Fast Finit Intelllftft Banietkltzona.N.JL <br /> Lake Havasu Cjjv 0jjjcq 142 <br /> kytaf staA�p too,mcc.110cl,81.0. <br /> Bank Lake hdv&SU City.Arizona 86403 <br /> ('Or <br /> IMU each IRA& <br /> i Idlka------ X ?Ov.vv <br /> P PLAN:C:HEC:K (Installation or Repair) <br /> L ;i- A V KA ki"r <br /> A <br /> PLAN CH K R E C E I V ED "--'---- <br /> N <br /> PLAN CHECK FEE $30.00 each SUBMISSION/RESUBMISSION <br /> JEN <br /> t!CE V! --_ <br /> E ;C <br /> C). (Do <br /> ()0 <br /> REPAIR <br /> R TANK REPAIR FEE $110-00 each TANK <br /> E <br /> P <br /> G P <br /> R/CL.� <br /> P <br /> A PIPI�NGREPAIR REPAIR/CLOSURE/REMOVAL AL L <br /> /CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION IN <br /> (when applicable) (wINSPECTION <br /> SAMPLING INSPECTIONhen applicable) (when applicable) <br /> FEE : $30-00/hri FEE = $35.00/hrl FEE $35.0 <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD <br /> CHECK CASH RCVD BY DATE RECEIVED PERMIT I <br /> fling M1 <br />