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12/28/2004 16:30 20946 <br />FIFTH FLOOR <br />PAGIL D-' <br />*3 <br />1 <br />1MJtsAWIN CMMTT KOLIC REALTN SERVICZ:S • ENVINOWNTAL HEALTH OIV'SIOM <br />LMEROMPO STORAGE TANK PROGRAM • FEE W R KSHEET <br />FACILITY SiPE NAME <br />FACILITY CONTACT NAME <br />ACILITT ADDRESS <br />SITE PHONE t With AREA COOS <br />'ITT Surf <br />�T�� <br />PIP CODEA <br />• of TANKS <br />TI <br />P <br />06 <br />et SITE <br />p <br />®PIII�NG NAME <br />APPLICANT CONTACTNAME <br />�y <br />II <br />Good <br />/���•�/` <br />` `"" 4��.X l (jam e-� ' . / ( GW 6�- �YJ• .,r—Q C, <br />IANC ADDRESS <br />� <br />APPLICANT <br />PRONE t 41TH AREA CODE <br />tT! <br />i <br />1�133J <br />2-0qf Y6 ' <br />STATEI ZtP CODE TYPE Of APPL' <br />G�S'Z� (Ctowr Ir*stallatl <br />�, <br />ecc.1 <br />ro1nL <br />i ANNUAL FACILITY FEE (Prior to Jill 1, 1991) . $100.00 <br />1906 1987 1988 <br />1989 <br />1990 <br />AI <br />C' <br />xxxx xxxx xxxx <br />xxXX <br />xxxx <br />S xxxxxxxx <br />1 FACILITY PENALTY FEES ASSESSED (If-- <br />Applitoble) <br />XXXX xxxx xxxx <br />xxxx <br />, xxxx <br />! xxxxxxxx� <br />V TANK FEE = 1110.00/IANK (prior to Jsruary 1,1991) <br />1170/TANK (After January 1, 1991) <br />E <br />I F <br />1 Ttnks • <br />(m it tfPlY t by too for <br />1965 <br />1 1969 <br />1490 11991 1992 <br />1993 <br />1996 <br />1995 <br />)996 <br />1997 <br />1998 <br />i <br />iA <br />each Tgmr tppllCabl®) <br />xxxx <br />xxxx <br />xxxx I xxxx jxxxx <br />S <br />I' <br />IANK PENALTY FEES ASSESSED <br />XXXX <br />xxxx <br />xxxx xxxx (xxxx <br />L <br />S <br />STATE SUACAAAGE FOR NEV FACILITIES ONLY.t18.50 <br />iI <br />t <br />t Tsnks x Sd,00 <br />1988 through 1993 (1156) <br />1993 thr"h 1997 (1156) 1998 <br />SURCHARGE FOR 1998 <br />XXXXXXXXXXXXXXXXXXXxxxxxxxx <br />xxxxxxXXXxxxxxxxxxxxxxx <br />s <br />CI PERXANENf CLOSURE (Agmoval or Authorltat! Closure•fn•PlIll <br />I TANK I.D. ?(S) <br />L <br />0! :LO" F FEE , 118.00/hour (3 hours mini"/TANK) <br />t TANX(s) x S2Ji,00 <br />_ <br />I s <br />U' P ART CLf)st/ILE (DlM Rev(aw t Inspections) <br />A <br />TANK 1.0, X(s) <br />E PEMPCxIART CLOME FEE • 178,00/hoer 0 hours minimem/FACILITY) <br />1236.00 min(nn <br />i <br />g <br />Pi <br />L <br />IRSTALLAITIONI PLAN CHECK (Plan Review 6 CoM frvction Inspectio ns) <br />IANK 8.0. A($) <br />A <br />-- <br />1 <br />PLAN CHECK FEE a 113•00/hour (8 hours minflnm/FACILITY) <br />$624.00 mini" <br />S <br />A <br />AEPAIA FEE (Voris l®n 44view 6 Construction Inspections) <br />TANK I.D. /(s) <br />E <br />P <br />TANK LINING REPAIR FEE a 178,00/hour (3 hours mininun/TANK) <br />A <br />f Ulill x 1234.00 ■ <br />S <br />1 <br />PAAK AETROFIT REPAIR FEE a $71.00ftur 0 hours min./FACILITY) <br />m t234.00 minims" <br />i <br />LA <br />I <br />S <br />P(PINO AEPAIA FEE : 178.00/haur 0 hours minfm4n/FACILITT) <br />■ 3234,00 minlmlm <br />S Z—?zi <br />AI fRANSFEA FEE ® 1120.067 UNAUTHORIZED RELEASE EVALUATION = !713.00/hr <br />1 <br />1 <br />9 <br />C, CORSULTATIOx FEE _ 178.00/hr SAMPLING INSPECTION FEE <br />I <br />$78,00/hr <br />g <br />1018E DUE S <br />% OfFICX USE OMLT <br />mom9' <br />SVEEp4 1 ui Liu ro EMIR w J`I�' <br />LOC E 51ST CODE AMOUNT RECEIVED CHECK t/CASH ED RECEIvaT <br />COMPUTER fCCA) <br />DATE RECEIVED <br />eo>�xwa•••t=. .� rtmnorM cam (aa9�aa+ <br />�a>cxniv�rnrmimrors x^! i:.. enr1N• a onm..ax!mp rtrrla!Iv^rnr anon urr,,N:�.+"v� �_frlot�Irr�nrmn - � i �i,� ; <br />