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IAN BM PUBLI; NEALTN SERVICES - ENVIRONPIENTAL HEALTH OIVSIOM <br />UNINVEROMM STORAGE TANK P FEI,WRKSHEIT <br />FACIE TT CONTACT AME <br />SITEPNONE N w t AREA CODE <br />- ®! <br />STATE ZIP CODE / of TANKS <br />fSZv 2 at SITE <br />APPLICANT CONTACT NAME <br />i <br />APPLICANT PHONE N WITH AREA CODE <br />Zo6 3 <br />SPATE 21P CODE 'TYPE of APPLICATION <br />(Closure, tnstallatfon, etc.) ll�. <br />FACILITY SITE NAMES <br />TANK I.D. x(s) <br />L <br />.;ACILITY ADORES$ <br />0 <br />CLOSURE FEE a $78.00/hour (3 hours minfmua/TANK) <br />1986 <br />1987 <br />1988 <br />CITY <br />A <br />P <br />MOMMY CL ! (P(MI Rlvfew i Inspeetlans) <br />TANK I.D. S(s) <br />AVP /BILLING NAME <br />L <br />n <br />I <br />C <br />LING AOORESS <br />A <br />s <br />A. <br />T <br />CITY n <br />FACIE TT CONTACT AME <br />SITEPNONE N w t AREA CODE <br />- ®! <br />STATE ZIP CODE / of TANKS <br />fSZv 2 at SITE <br />APPLICANT CONTACT NAME <br />i <br />APPLICANT PHONE N WITH AREA CODE <br />Zo6 3 <br />SPATE 21P CODE 'TYPE of APPLICATION <br />(Closure, tnstallatfon, etc.) ll�. <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-fn•Ptace) <br />TANK I.D. x(s) <br />L <br />TOTAL <br />0 <br />CLOSURE FEE a $78.00/hour (3 hours minfmua/TANK) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to JWMry 1t 1991) • $100.00 <br />MOMMY CL ! (P(MI Rlvfew i Inspeetlans) <br />TANK I.D. S(s) <br />R <br />E <br />f DMAY MOMI PEE it !78.00 /hour (3 hours mfnfmua/FACILITY) <br />$236.00 minimum <br />s <br />A <br />xxxx <br />xxxx <br />xxxx <br />XXXx <br />xxxx <br />S xxxxxxxx <br />C <br />T FACILITY PENALTY FEES ASSESSED (if Applicable) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />s xxxxxxxx <br />t <br />V TANK FEE • 550.00/TANK ( riot to Jerxuary 1,1991) <br />5170/TANK <br />(After January 1, 1991) <br />E <br />tanks <br />1988 1989 1990 <br />1991 1992 <br />1993 1996 <br />1995 <br />1996 <br />1997 <br />1998 <br />F (Ruttiply 1 -3i -fee for <br />kxxx xxxx xxxx <br />xxxx xxxx <br />s <br />A each year apptioable) <br />C <br />TANK PENALTY FEES ASSESSED <br />xxxx xxxx xxxx <br />xxxx xxxx <br />s <br />L <br />I STAtE SURCHARGE FOR NEW FACILITIES ONLY*518.50 <br />f <br />T <br />I tanks x 58.00 <br />1988 through 1993 ($56) <br />1993 through 1997 (S56) <br />1998 <br />1 xxxxxxxxxxxxXXXXXXXxxxxxxxX <br />I xxxxxxxxXxxxxxxxxxxxxxx IS <br />SURCHARGE FOR 1996 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-fn•Ptace) <br />TANK I.D. x(s) <br />L <br />0 <br />CLOSURE FEE a $78.00/hour (3 hours minfmua/TANK) <br />0 TANK(s) X 5234.00 • <br />S <br />$ <br />U <br />MOMMY CL ! (P(MI Rlvfew i Inspeetlans) <br />TANK I.D. S(s) <br />R <br />E <br />f DMAY MOMI PEE it !78.00 /hour (3 hours mfnfmua/FACILITY) <br />$236.00 minimum <br />s <br />P INSTALLATION PUN CHECK (Platt Review 6 Construction tnspectlonsD TANK I.D. 0(s) <br />L <br />A <br />X PLAN CHECK fit • 578.06/hour (8 hours mfnfiKW FACILITY) • $624.00 minimum s <br />I; <br />REPAIR FEE (Wrkplan A#Vfew t Construction Inspections) <br />TANK 1.0. 9(s) <br />E <br />P <br />SANK LININO REPAtk FEE +.578.00/hour (3 hours mfnfmm/TANK) <br />0 TANK(s) X 5236.00 • <br />s <br />A <br />I <br />TANK RETROFIT REPAIR FEE a .00/hour (3 hours min./FACILITY) • mfnfaam <br />s <br />R <br />PIPING REPAIR FEE a $78.00/hour (3 hours mfnftmm/FACILITY) •.: S234.00 minimum <br />S <br />N TRANSFER FEE a !20.00' <br />:I <br />•s <br />C CONSULTATION FEE • $78.00/h <br />FCA OFFICE USE ONLY <br />SWEEPS I I COMPUTER S LOC <br />EN 23 032 (REVISED 1.12.98) <br />UNAUTHORIZED RELEASE EVALUATION • S78t00/hr S <br />r SAMPLINO INSPECTION FEE • 578,00/hr s <br />TOTAL OM S Z-69, <br />�!!!rnar.!m!aum <br />u '! uii!!u!!!Euruueu!a <br />CODE DIST CODE AMOUNT RECEIVEDCHECK R/CASH RECEIVED BY DATE RECEIVED <br />5 I I <br />