Laserfiche WebLink
A <br />P <br />P <br />L <br />I <br />C <br />A <br />R <br />T <br />ta J01MISIC MAILIC HEALTN SERVICES - ENVt TAL HEALTH DIVSION <br />UNDEWOUND STORAGE TANK P - FES UORKSHEET <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />1987 <br />1988 <br />ACILITT AGGRESS <br />�i A3 <br />SITE PHONE 0 with AREA CODE <br />CI <br />SPACE <br />P CODE <br />+► of TANKS <br />It SITE <br />APP /BILLING NAME <br />APPLICANT CONTACL.AAME <br />, <br />PLAN CHECK FEE • $78.08/hoar (8 hers minlax•m/FACILITY) %624.00 minimum <br />PSING AD <br />., <br />APPLICANT PRONE N WITH AREA CODE <br />X)(Xx <br />STATE <br />YIP CODE <br />TYPE of APPLICATION <br />Azo--� <br />C <br />(Closure, Installation, etc.) <br />TOTAL <br />PEW9EXt CLOSURE (Removat or Authorized Closure -fn -Place) <br />1944 <br />1987 <br />1988 <br />1 1989 <br />1990 <br />P AAY CLOM PEE a 5712.00/hour 0 hours mintOWFACILITY) <br />ANNUAL FACILITY FEE (Prior to January la 1991) • $100.00 <br />s <br />A <br />0 TANK(s) X 5234.00 <br />S <br />R <br />PLAN CHECK FEE • $78.08/hoar (8 hers minlax•m/FACILITY) %624.00 minimum <br />xxxx <br />XXXX <br />X)(Xx <br />XXXX <br />xxxx <br />S xxxxxxxx <br />A <br />C <br />PIPING REPAIR FEE a.00/hour (3 hours mtntrte n/FACIItTY) s inteun <br />s <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I <br />XXXX <br />xxxx <br />XXXX <br />XXXX <br />xxxx <br />S xxxxxxxx <br />V TANK FEE _ %50.00/TANK ( rior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />I Tanks 1988 1989 1990 1991 <br />1992 1993 1994 1995 1996 1997 1998 <br />F (euttlp(y / t!y fee for <br />XXXX <br />S <br />A each year applicable) xxxx XXXX xxxx xxxx <br />C <br />I TANK PENALTY FEES ASSESSEO <br />xxxx XXXX XXXX <br />xxxx <br />XXXX <br />S <br />L <br />I STATE SURCHARGE FOR REV FACILITIES ONLY418.50 <br />; <br />1 <br />I tanks x58.00 <br />1988 through 1993 (%56) <br />1993 through 1997 (S56) <br />1998 <br />I <br />xXXXXXXXXXXXXXXXXXXxxxxxxxx <br />xxxxxxxxxxxxxxxxXxxxxxX <br />I <br />S <br />SURCHARGE FOR 1998 <br />PEW9EXt CLOSURE (Removat or Authorized Closure -fn -Place) <br />TANK I.O. 1(s) <br />CLOSURE FEE • $78.00/hour (3 hours minfwWTANK) <br />L <br />P Y CL E (PISA Rtviaw A Inspections) <br />TANK t.D. Sits) <br />P AAY CLOM PEE a 5712.00/hour 0 hours mintOWFACILITY) <br />$234.00 minimum <br />s <br />P <br />INSTALLATION PLAN CHECK (Plan Review i Construction inspections) <br />TANK I.D. 0(s) <br />L <br />E <br />P <br />A <br />0 TANK(s) X 5234.00 <br />S <br />R <br />PLAN CHECK FEE • $78.08/hoar (8 hers minlax•m/FACILITY) %624.00 minimum <br />S <br />R <br />REPAIR FEE (Vorkplan R♦view i Construction Inspections) <br />TANK I.D. S(s) <br />E <br />P <br />TANK LINING REPAIR FEE 0 5713.00/hoar (3 hours minlmun/TANK) <br />0 TANK(s) X 5234.00 <br />S <br />A <br />I <br />WK RETROFIT REPAIR FEE a S78.00/hour (3 hours min./FACILITY) * S234.00 minimtm <br />I S <br />R <br />PIPING REPAIR FEE a.00/hour (3 hours mtntrte n/FACIItTY) s inteun <br />s <br />N tRANSFEA FEE f 520.00' UNAUTHORIZED RELEASE EVALUATION a S78t00/hr <br />1 <br />C CCiiSULTATION FEE • S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />FCR Of F I CE USE ONLY <br />SVEEPS f COMPUTER 0 LOC CODE GIST CODE AMOUNT RECEIVED CHECK N/CASH <br />% <br />Ex 23 032 (REVISED 1.12.98) <br />t3 <br />' S <br />TOTAL DUE S �.. e <br />u i ;r111tN a 5u�iiuu�au:;umuarer:a <br />RECEIVED BY GATE RECEIVED <br />;I <br />i <br />......•......::::::::::.: <br />