Laserfiche WebLink
UNDERGROUND I UKAUL I ANr,, vvvr�r�•�� <br /> FACIL►TY..vNTACT NAME <br /> FACILrTY NAME <br /> �7- / SIT PHONE#WITH AREA CODE <br /> FACILITYSORE S <br /> / ZIP CODE #OF TANKS AT SITE <br /> CITY STATE <br /> /t <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT PHONE TM WITH AREA CODE <br /> APPLICANT MAILING ADDRESS <br /> dr <br /> CITY <br /> STATE ZIP CDD= CIRCLE WORK TO BE DONE: <br /> !,sure Installation Repair Retrofit <br /> A <br /> CTIVE <br /> 1997- ggg 2000 2001 2002 <br /> Y FEE+1 TANK (s��0)x(#tanks)x($aye apphrable) <br /> TANK ' <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTOR IN A CUPA PROGRAM=517.50/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK ID (s): CLOSURE ' =-=S267/TANK t TANKS X S267= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORA CLOSURE FEE=6267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> tan Check and Construction Inspections <br /> : PL• CHECK FEE=S712/FACILITY <br /> TANK ID#(s) <br /> REPAIR PLAN CHECK <br /> TANK ID (s): <br /> TANK LINING REPAIR FEE =6267/TANK FtTANKS X 6267= <br /> TANK RETROFIT REPAIR FEE =6267/FACILITY <br /> PIPING REPAIR FEE =6267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = S 2D <br /> CONSULTATION FEE = S 89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S B9/HOUR <br /> SAMPLING INSPECTION FEE = S 89/HOUR <br /> A11 FEES ARE BASED ON THE 589 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 7i FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 3/15!02) <br />