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01/08/2004 08:23 20946834 FIFTH FLOOR PAGE :_1 p�rr�� r�/aetarvnryav Iv %-VUII'q I T CICVV�irt^G/�VpIV;pIVII�tV IAL/C- LAgLI M UC I MI --N I H C -g - FACILITY NAME1 FACILITY CONTACT NAME (w-.4,5 5 T N7 I ca kJ c 10 D >4- iv 6t' -r 'V --- FACILITY ADDRESS SITE PHONE # WITH AREA CODE --� 7(-7 LAJ E3 4-k 3 3 1' 7 CITY STATE ZIP CODE # OF TANKS AT SITE - $500 FEE INCLUDES FACILITY FEE+ 1 TANK STAATE� ZIP CODE APPLICANT BILLING NAME APPLICANT CONTACT NAME -�_--_ J a i7f�-'v Cr c acv Jc3s� l�A(`1 Cr-Tr2-X Y,, J APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CGDE 3 3 1' 7 F t.-! N T M a Ij 1 P 1 VIE 6 6 C- ® CJ ® 0) CITY $500 FEE INCLUDES FACILITY FEE+ 1 TANK STAATE� ZIP CODE CIRCLE WORK. TO BE DONE: ^- _ GosuraStdll2atio Repair Retrofit si"ti J0 E - - �, t $125 PER TANK AFTER FIRST TANK ACTIVE FACILITY TANK ID # S CLOSURE FEE = $279 / TANK # TANKS X $279 1998 1999 2000 2001 2002 2003 $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($17D) X Vftmks) ($170)x(Xtanks) SAMPLING INSPECTION FEE _- $ 931 HOUR - - $125 PER TANK AFTER FIRST TANK ---- $?-J- $� TANK TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK ' $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00! FACILITY _1 PERMANENT CLOSURE Removal or Permitted Closure In Place TANK ID # S CLOSURE FEE = $279 / TANK # TANKS X $279 TEMPORARY CLOSURE Plan Review and fns ections) TANK ID # (5) : TEMPORARY CLOSURE FEE = $2791 FACILITY INSTALLATION PLAN CHECK Plan Check and Construebon Inspections) TANK ID # (s) : PLAN CHECK FEE _ $744 / FACILITY REPAIR PLAN CHECK TANK 10 # s TANK RETROFIT REPAIR FEE _ $2791 FACILITY (use for monitoring equipment, s .11 buckets. tank sumps, misc-) PIPING REPAIR FEE = $2791 FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE = $ 20 CONSULTATION FEE = $ 931 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR SAMPLING INSPECTION FEE _- $ 931 HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. ®y OFFICE USE ONLY SERVICE REQUEST A FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE_ RECEIVED SR £H 23 032 (REVISED 11124103)