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m 111 <br /> _ p p n IN LOCAL HEALTH D RICT <br /> o <br /> o N Z 0 STORAGE TANK PROGRAM - FEE WORKSHEET <br /> p ~ FACILITY CONTACT NAME <br /> o <br /> o 1 SITE PHONE 1 WITH AREA CAW <br /> C. m <br /> m STAT 71P CODE 1 of Tanks <br /> r o 0 at Site <br /> O M Z APPLICANT CONTACT NAME <br /> .3d o p <br /> r O m <br /> o APPLICANT PHONE 1 WITH AREA C009 <br /> m a o <br /> STA, 71P'CODE TYPE of APPLICATION <br /> CLoeuRE, INETALLATtON, ETC. <br /> Z --- —_ -- - - - - — TOTAL <br /> 1987 1988 1989 <br /> m _ <br /> PA MEN'r <br /> 1(7:T1988 1989 <br /> A � <br /> 0 <br /> N <br /> O N IVy N <br /> cc <br /> s _ <br /> O a z SAFETY CODEESSec 25287 for applicability) <br /> m L — <br /> 37 1988 =19897 f <br /> ° N n <br /> o <br /> a z <br /> z0 years) <br /> O 1 Tanks x 580.00 f <br /> � Z <br /> m iti Rl3. z CC) <br /> G' <br /> N N � <br /> mZa Th <br /> �3� (P 'z OO a J <br /> m = w Rid OO <br /> o -- f <br /> Ny oO z -- <br /> r OO — — <br /> 1 Tanks x $110.00 f <br /> IA PING REPAIR./CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> ---.._..... .. .......__...—--- — --- --- --- ---------... -- <br /> FEE = $30.00/hr[ <br /> FEE _ $35,00/hrL --___--- FEE = $35_00/hr(_..._..._—. <br /> OFFICE USE ONLY <br /> TOTAL DUE $ MDO-11 <br /> -- <br /> SWEEPS 1 COMP 1 LOC CODE 'DIST CODE AMOUNT DUE AMOUNT RCVD CHEC 1/CASH RCVO BY DATE RECEIVED PERMIT 6 <br /> ._..._ <br /> I <br />