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SAW 1QACUIM PU8LIC HEALTH SERVICES - ENVIRCNMEIffAL Tit DIVISION <br />STORAGE TANK PROGUX - FEE y <br />S <br />FA LITT SITE NAME FACILITY CONTACT NAME <br />I. <br />P5 r <br />L: <br />A <br />Al <br />?�_AN CiECX F = 573.00/hour (8 hours minima m/FAC:LITY) <br />T <br />E <br />FACILITY ADORESS,I <br />� <br />SITE PHONE with AREA CODE <br />CjC%0 <br />L <br />I <br />Cl77 I SZ.1 <br />/�:w <br />PI a of TANKS <br />ZI_ <br />SITE <br />A <br />E, <br />Pj <br />at <br />� X <br />P <br />P <br />APPLI GN /BILLING NAME <br />I APPLICANT CONT NAME <br />L <br />= 5234.00 minimumS <br />J��►n� <br />I <br />AN <br />MAILING ADDRESS <br />APPLlCAH; PHONE V7ITH �-LE <br />I S <br />Y �V� <br />Jj <br />T <br />MI TRANSFER F= = SZD.DD I UNAUTHCIR17cn RELY EVALUATICH = S7a.001hr I I <br />ZIP CC00E <br />` TYPE of APPLICATION <br />ICClcsure, Instaltaticn, etc.) <br />S. <br />C =SULTATICN FE= = 578.00/hr I I SAMPLING INSPSC710M FEE <br />= 578.00/hr ` I <br />TOTAL <br />PSRMANEIT CLOSURE (RemovaL or AutnorizeC Closure -in -?lace) ! TANK 11.3. +ts) <br />L <br />01 CLOSURE F__ = S78_00/hour (3 hours minimsm/TANK) ! '- TANK(s) X 5234.00 = j S <br />S' <br />UI TE:-.PCRAR- CLOSURE (?Ian Review L Insmec,ions) TANK ..3. +ts) <br />R, <br />E TEMPORARY CLOSURE = ST3.00/hour (3 hours ninirtam/FAC:LiTY) ! SZ' -U-00 minimum ` S <br />?! <br />ENSTALLATiCN PIAN CHECA CPlan Review L OarsSt:sc_ion lnsae=:ians)I <br />TANK ..D. -(s) <br />L: <br />A <br />Al <br />?�_AN CiECX F = 573.00/hour (8 hours minima m/FAC:LITY) <br />= 5524.00 minimus <br />S <br />RI <br />REPAIR .-c. (NorkmLan Review L Canst:sction Insaections) <br />TANK I.D. S(s) <br />E, <br />Pj <br />TANK LINING REPAIR FE= = 578.00/hcur (3 hours minimum/TANK) <br />TAMKCs) X 5234.00 = <br />S <br />A <br />Ij <br />TANK RETROFIT REPAIR FE. = 578.00/hour (3 hours mi rt./FACILITY) <br />= 5234.00 minimumS <br />Z3 ,� <br />Rj <br />PIPING RE.°A!R FEE = 578.00/hour C3 hours miniaasm/FACILIT'•') <br />= 5234-00 minimus <br />I S <br />MI TRANSFER F= = SZD.DD I UNAUTHCIR17cn RELY EVALUATICH = S7a.001hr I I <br />I S <br />IiI <br />S. <br />C =SULTATICN FE= = 578.00/hr I I SAMPLING INSPSC710M FEE <br />= 578.00/hr ` I <br />S <br />lutwu Wu I - %d- -I-+. - - I <br />FOR OFFICE USE CULT <br />SWEEPS 3 I CO1PUTER I LOC CODE i GIST CCOE i AMOUNT REI --.VM I CiECL Z/CASH RECE-IVE7 37 i GATE <br />E I ! !S I ! <br />