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SAN NO'UNDERGROUND* <br /> STORAGE TANK PROGRAM FEE WORKSHEETN <br /> UND <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> rCILffY ADDRESS I <br /> Si I PHONE m WITH AREA CODE <br /> pttF G P�E�1- 20 474-4,;7I# <br /> CITY <br /> STATE I ZIP ODE T-OF TANKS AT SITE <br /> ' F ICN CSM (z7TOC(LT0 ca I 9523 <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> t-1� I � cjCDT 1,4+•l�-1�ILI- <br /> . APPLICANT PHONET WITH AREA CODE <br /> APPLICANT MAILING ADDRESS <br /> ' 3 ► 1oRTif Mc�olr�E 8 45 l�a(o0 <br /> Il >✓Ufl. 70 7(� <br /> CITY a <br /> STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> PE FPrL!1 M A <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY 1999 2000 2001 <br /> $500 FEE INCLUDES FACILI7Y FEE+ 1 TANK (Si 70)X(:tanul X(.of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> S <br /> ' TANK PENALTY ASSESSED +� <br /> TANK SURCHARGE=S8/TANK S <br /> ' STATE SURCHARGE OR FACILITIES NOT ALREADY ON INVEN OR IN?.CUPA PROGRAM 'SIU/FACIVTY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) I' S CLOSURE PEE=5261 !'ANK m TANKS X 5261 = (Q <br /> TANK 10+(s) <br /> TEMPORARY CLOSURE I S <br /> TANK 10 (s): <br /> (Rao Review and Inspections) <br /> ' TEMPORA:RY CLOURE S :EE=5261 / FACILITY <br /> INSTALLATION PLAN CHECK I' S Plan Chedc and Construction Insoe(:tcns) <br /> PLAN CHECK FEE=5696 / FACILITY <br /> TANK 10 T(s) <br /> REPAIR PLAN CHECK - <br /> TANK ID R(s): i I S <br /> m TANKS X 5261 =. <br /> TANK LWING REPAIR FEE _$261 I TANK S <br /> TANK RETROFIT REPAIR rcE =5261 /FACILITY S <br /> PIPING REPAIR EE =5261 / FACILITY _ <br /> MISCELLANEOUS I $ <br /> TRANSFER FSE = S20 <br /> CONSULTATION FEE 5 a HOUR I S <br /> ' UNAUTHORIZED RELEASE EVALUATION``E = 5 87!HOUR S <br /> SAMPLING INSPECTION rc. = 5 87/HOUR <br /> ' AU.FE39 dye 8A5cD ON THE seT HOURLY RATE- TIME THAT EXCEEDS FEES PAIQ'NIL:3E 31LLED TO APPUCAN7. <br /> OFFICE USE ONLY <br /> REL=IVED 8Y <br /> LITlI DATc RECEN <br /> � AMOUNT RECEIVED I C:iEC1C 9 I <br /> I SERVi[E REQUEST rAC110 j <br />