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F)1/08/2004 08:23 2094683433 FIFTH FLOOR PAGE :_1 <br /> T+-; IVAN J%- k VU1V 1 T r-1-4y 1KV1.4MQ17 Hr- <br /> I L r1AL I H Ut 'I MtIV I <br /> UNDERGROWUV� STORAGE TANK PROGRAM F .;VORKSHI=ET <br /> FACILITY NAME FACILITY CONTACT NAME `--- <br /> la-'A,5 STAT I cv. I\•/ doe D P-Irl (j--r CZ-A-iU ----- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE ^'- <br /> 71-7 w - 8 4-k s T rL.EE - <br /> CITY STATE ZIP CODE #OF TANKS PT SITZ: <br /> SToc.IC—-ruIv CA q C) - <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME - <br /> J O . D/% T�z p,,Iv Joh b a_(\j CT--T r2--)N-. uu <br /> APPLICANT MAILING MAILING ADDRESS APPLICANT PHONE#WITH AREA CGDE -- <br /> 3 31 _7 F L.-I N T M 0 Iv Ti a R-I VIE 4�E G (. ra - O 0 o C) <br /> CITY STATEZIP CODE CIRCLE WORK,TO BE DONEi �'-- <br /> S �o <br /> Closure StdUdtio Repair Retrofit <br /> ACTIVE FACILITY — <br /> $SOD FEE INCLUDES FACILITY FEE+1 TANK tsi 99I 8 1999 2000 2001 2002 2003— 3�Z <br /> $125 PER TANK AFTER FIRST TANK fmanks) ($t�o)x(tttanks) O <br /> TANK PENALTY ASSESSED _ <br /> TANK SURCHARGE=$151 TANK I $ -2 X30 1%2. <br /> STATE SURCHARGE FOR FAClUT(C$NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=•$24.D0/FACII.ITY J $ Z Z3 15 <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): CLOSURE FEE=$2791 TANK #TANK$X$279= $ —-] <br /> TEMPORARY CLOSURE --- <br /> Plan Reviewand Ins ectlons) <br /> TANK ID#-(s):: $ <br /> ( TEMPORARY CLOSURE FEE_$279 J FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construdon Inspections) _ <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $I <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE _$279!FACILITY (use for monitoring equipment,S III buckets.tank sumps,misc. $_--.- <br /> PIPING REPAIR FEE _$2791 FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ ` <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY �__ <br /> SERVICE REQUEST JF FACILITY 10 AMOUNT RECEIVED CHECK# RECEIVED BY DATE:RECEIVED <br /> sR ou610 15)--7 (off 420 S' 3 3°.[Dy.. <br /> EH 23 032(REVISED 11134103) A-p—V 0 <br />