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p', �' i <br /> SANOQUIN COUNTY F DOS C'o�Asgha ropes oy�neCIO <br /> UNDERGROUND <br /> STORAGE-0 oo�PyF °d o+'s JsD q <br /> dh, % <br /> FACILITCY N�A1ME 7p��efp es�� qF pso abs0 4p �I <br /> U� 1 J �'Np 79 03 44 O <br /> e <br /> W O c a <br /> FACILITY ADDRESS SffE oY, 6p le A <br /> yoo u Ap e� <br /> a5oo w . l,vd ��� CO <br /> CITY 1, STATE <br /> 231P CO <br /> T `1 S 4 0 , c4 DJC 11, <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �5$ eum Tan nC� �wQ o <br /> APPLICANT MAILING ADDRESS APPLICANT E#WITH AREA CODE <br /> OS TC Y Cane�3 �l�d. X59 585 8 15e <br /> CITY STATE IF CODE CIRCLE WORK T I BE DONE: <br /> Ne I N�r C /1 Cbsure Installation Repair Rem <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($1m)x Itul <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANKID# s CLOSURE FEE=f279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and In ns $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction In $ <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $.� 9 <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for mwiODrin equipment, ill buckets.tank sum ,mise. d-7 '•/ <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping.under-dispenser contanmenL ect- <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALLIATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT IXCEEDS FEES PAID WILL SE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILRY ID AMOUNr RECEIVED T CHECK# I RECEIVED BY DATE REGENED <br /> SR <br /> EH 23932(REVISED SIM" <br />