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SNI JOMUM 1 <br />I <br />S FACILITY SITE NAME <br />I <br />T <br />E FACILITY SS L� <br />s <br />CITY <br />A <br />P <br />P APPLICANT/BILLING NAME <br />I <br />C MAILING ADDR SS 41 <br />A „3? <br />N <br />T CITY �! K <br />hlA <br />�' �. i..lY �". {''!. :•WAC' � '::1 '1 'Y;I�z. <br />-� ! 7 f FACILITY CONTACT NAME <br />Ss � <br />SITE PHONE # with AREA CODE <br />STATE ZIP CODE of TANKS <br />at SITE <br />APPLICANT CONTACT NAME <br />APPLICANT WONE # WITH JQA CODE <br />STATE ZIP CODE TYPE of APPLICATION <br />L.A- I 4,L4 C -X. I (Closure, Instattation, etc.) <br />Glum <br />P INSTALLATION PLAN CHECK (Ptah Review $ CoirblC—ion Inspections) TANK I.D. #(S) <br />L <br />A�Q lc Is <br />N PLAN CHECK FEE % 578.00/hour (5 hours minimum/FACILITY) = S624.00 minimum <br />M TRANSFER FEE = 520.00 UNAUTHORIZM RELEASE EVALUATION = S78.00/hr S <br />I <br />S <br />C CONSULTATION FEE = S78_00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br />TOTAL MX 'a 3 <br />OFFICE USE ONLY <br />_-: <br />SWEEPS it ( COMPUTER <br />EH 23 032 (REVISED 5-27-97) <br />LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASA RECEIVED BY t{ DATE RECEIVED <br />S I <br />