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y'. <br />IFPFAC!LITY/SITE NAME <br />STREET ADDRESS <br />CITY <br />kJAPPLICANT/FILLING NAME <br />I11AILING ADDRESS <br />A C!T <br />I C —f it <br />UNDO 'OUND STORAGE TANK.. PROGRAM - FEE WORKSHEET <br />FACILITY CONTACTT+AME GJI �lI(Cln esSi�� <br />- /<SITE PHONE WITH AREA CODE <br />STnTE LIQ DD[ I of <br />Tar k5 <br />at Site-I"GJv <br />r0_ _ . _R..�15. d ... _.... --- ---� --- <br />APPLICANT CONTACT NAME <br />�.rF�.....cS�K>l._G� 1KG........ k✓`�1P_ ssr.�ls� <br />APPLICANT PHONE I WITH AREA CODE <br />STATE ZI° iODE YPE of APPLIDATION <br />' -A I f CLOSURE, IHSTALLATfON, ETC.R61%,10✓/L4— <br />P�PLAN <br />,A <br />IIIIfLAiI <br />CHECK (Ina al!att m or kepa-ri <br />CHECK. FEE S30.00 each SUFM[SSIOW/R'ESUDMIS IG!I <br />5 <br />IREPAIR <br />... <br />._ — <br />- — --- .. <br />R TANK REPAIR, FEE - 5110.00 ea:n TANK <br />I Tanks <br />z $110 n0 <br />5 <br />E------ -. <br />— — <br />f'----------__.___.------..._..._.-----......._...----._................. <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees <br />are per hour, mininum one <br />_.._ ._... <br />hour to he <br />paid or, plan submittal) <br />_ .---- <br />- <br />---- <br />R UNAUTHORIZED RELEASE EVALUATION <br />.............._.__...--........ ..... _......._... <br />CONSTRUCTION INSPECTION <br />SAMPLING <br />---._... <br />INSPECTION <br />When applicable) <br />(when applicable) <br />(when <br />applicable) <br />FEE - 530,00/hr[ <br />FEE 13 VO/hr <br />FEE <br />13,.00/hr <br />S <br />TOTAL DUE <br />- - <br />OFFICE USE ONLY <br />SWEEPS I COMP I ILO( CODE DIST CODEI AMOUNT DUE AMOUNT PCVD CHECK 9/CASH I FCVD BY i DATE RECEIVED PERMIT I <br />