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SAN JOADUIX •"'LINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> RGROUMD STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY SITE NAME ee� -/ FACILITY CONTACT NAME <br /> T l2rd -G'IeVen Jn�r� ITII I <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 2725 Gouty•'' Club e)IVJ <br /> CITY STATE ZIP CODE # of TANKS <br /> A St ,k-ton GA g5ZO4 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> LIRHC n rou InG. F.HI a G(anino <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A6�5o Howe ven 504- (qi&) l04Cv-4Cb3 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION Tank <br /> 5 aamen{o GA �je Z (Closure, Installation, etc.) GI®Sure <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX xXXX XXXX XXXx xXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) xXXX Xxxx %X%X %XXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 ( 1997 <br /> F (multiply # by fee for <br /> A each year appLicable) xXXX xxxx XX%X XXXX Xxxx S <br /> C <br /> I TANK PENALTY FEES ASSESSED I xXXX xXXX %Xxx xXXX XXXX $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 IS <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1990 (856) 1991 through 1996 (856) 1997 <br /> SURCHARGE FOR 1997 xxxxxxxxxxxxxxxxxxxxXXXXXXx XXXXXXXXXXXxxxxxxXxxxxx S <br /> RCPERMANENT CLOSURE (Removal 'or Authorized Closure-in-P Lace) TANK I.D. #(s) <br /> LOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) L X 5234.00 = S7O2 <br /> EMPORARY CLOSURE (Plan Review & Inspections) TANK ID. #(s) <br /> EMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (WorkpLan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> MTRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY DATE RECEIVED <br /> EH Z3 032 (REVISED 5-27-97) . <br />