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I <br />P s 74 7i0 <br />I TANK I.D.:(s) <br />t <br />o <br />T <br />E <br />FACILITY A009ESS SITE PHONE 9 with AREA CODE <br />TOTAL. <br />3 2 O Z fin/, HAI 9 M f ,1 % 1V E L9 �7 _ zclO cam' <br />S <br />P <br />1986 1987 1988 <br />1989 <br />1990 <br />CITY <br />STATE <br />ZIP CODE <br />aP TANKS <br />A <br />�5—r e-%Aj <br />1 C49 <br />2 <br />at SITE 3 <br />TEMPORARY CLOSURE FFF = 578.00/hour (3 hours minimum/ FACILITY) <br />52,34.00 minin A <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />P <br />X= f 2x )= <br />r <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT NAME/ <br />L <br />/ <br />d.A L / P &rZ�l 109 <br />fCONTACT <br />} nocc x= ( X= <br />x= <br />C <br />MAILING ADDRESS <br />CODE <br />APPLICANT PHONE # WITH-31 <br />K <br />�v 31 , 5T nl�� d10 �L <br />1, vb3q _ � �5® <br />T <br />CITY <br />STATE <br />ZIP =ETYPE <br />of APPL <br />4 /U 79 ®9 /V/ -I <br />G,j <br />c1270,!;- <br />(Closure, nstatlation, tc.) <br />C{ <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) <br />I TANK I.D.:(s) <br />t <br />o <br />CLOSURE FEE = 578.00/hour (3 hours miniar---/TANK) <br /># TANK(s) X SZ4.00 = S <br />TOTAL. <br />S <br />P <br />1986 1987 1988 <br />1989 <br />1990 <br />TANK I.D. 4(s) <br />L FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />I <br />R <br />S <br />E <br />TEMPORARY CLOSURE FFF = 578.00/hour (3 hours minimum/ FACILITY) <br />52,34.00 minin A <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />X= f 2x )= <br />r <br />XXXX <br />xxxx <br />S xxxxxxxx <br />ITY PENALTY FEES ASSESSED (If Appticaote) <br />FF(muLtipty <br />} nocc x= ( X= <br />x= <br />XXX)t <br />S M)CcxXX <br />FEE = 550.00/TANK <br />CPrior to January 1,1991) <br />$170/TASIC (After Jamiary <br />1, <br />1991) <br />ks = <br />19,97 1988 1989 1990 1991 <br />1992 1993 1994 1995 <br />1996 1997 <br />4 by fee for <br />Ai <br />C <br />I <br />each year appticsbte) <br />TANK PENALTY FEES ASSESSED <br />xxxx xxxx XXXX xxxx xxxx <br />x= xxxx xxxx XXXX XX)O( <br />+ <br /># <br />E <br />j <br />$ <br />S <br />L <br />I <br />STATE SURCHARGE <br />T <br />Y <br />9 Tanks x $8.00 <br />1988 through 1990 ($56) <br />1991 through 1996 ($56) 1997 <br />XXXxXXXXXXXXXXXxXXXXXX)CO(XX <br />XXXXa X XX)= <br />S <br />SURCHARGE FOR 1997 <br />C{ <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) <br />I TANK I.D.:(s) <br />t <br />o <br />CLOSURE FEE = 578.00/hour (3 hours miniar---/TANK) <br /># TANK(s) X SZ4.00 = S <br />L <br />S <br />P <br />TANK LIVING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />U <br />TEMPORARY CLOSURE (?tan Review & inspections) <br />TANK I.D. 4(s) <br />I <br />R <br />S <br />E <br />TEMPORARY CLOSURE FFF = 578.00/hour (3 hours minimum/ FACILITY) <br />52,34.00 minin A <br />S <br />P <br />INSTALLATION PLAN CHECK (Ptan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />P <br />TANK LIVING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />N <br />PLAN CHECK FEE = 578.00/heir (8 hours minimum/FACILITY) = SU4.00 minimum <br />IS <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.A. #(s) <br />E <br />P <br />TANK LIVING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />9 TANK(s) X 5234.00 = <br />s23Y, ®® <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578_00/hour (3 hours mics./FACILITY) = 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />K TRANSFER FEE a 520.00 UNAUTHORIZED RELEASE EVALUATION a SM.00/hr 5 <br />f � <br />S <br />C CONSULTATION FEE = S78,00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br />W <br />