Laserfiche WebLink
SI <br />=AC:L '; 517c-'ti4iET <br />r.. <br />FAC Li t :t3TnCT NAMEJ <br />I <br />! <br />s✓ CG <br />co LZ.4�g/tl <br />E <br />FACILITY AOORESS <br />SITE PHONE ;9 With AREA CODE <br />I <br />D CoU 6 C UO <br />= 5234.00 minims= S <br />& <br />. <br />I <br />A <br />!! <br />CITY 1 I STATE i ZIP CODE : of TANXS <br />S 6420V !t '�%� ` 9J��Q� at SITE 3 <br />P <br />P <br />A?PLICANT/BILLING NAME <br />APPt1 CONT NAME <br />I <br />iy3 s r. B,c�o+e�w roc ANr� c� 2�o <br />GtJ. <br />C <br />MAILING AOORESS <br />APPY CANT HONE #SETH AREA CME <br />A <br />A M rF S Esc v <br />7/y - y 47 S'— <br />TI <br />CITY STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />rl r�arn..u. u:uJucc �cv�+vaa vc :acczraarazea Liassre-ln-YtdcS) ! TANK I.O. :(S) <br />L f <br />01 CLOSURE FEE = $78.00/hour (3 hours minim=ITANK) S TAdRK(s) X SZ4.00 = 3 <br />S' <br />U TEMPORARY CLOSURE (Ptah Review & IYtspections) I TANK I.O. 0(s) <br />R, <br />E! 7EMPCRARY CLOSURE r== ; 578.00/hcur (3 hours minimMVPACILITY) SZ34.00 minimum S <br />P INSTALLATION PLAN CHECK (Ptah Review & C4Mtr=.icn Inspectiom)� TANK I_0. +(s) <br />L <br />A <br />N PLAN CHECK FEE _ S78.00/hour (8 hot#'3 a tinitwxVFACILITY) Sb2b_QO minisS <br />R <br />E <br />REPAIR FEE (Workplan Review & Coutrwtion Inspections) <br />TANK I.D. R(s)_(.�N_&N04077 23 Q p <br />P <br />TANK LINING +REPAIR FU = S78.00/hour (3 hours minioAVTANK) <br /># TANK(s) X SM4.00 = S <br />A <br />I <br />TANK RETROFIT REPAIR rEE = S78_00/hour (3 hours min./FACILITY) <br />= 5234.00 minims= S <br />R <br />PIPING REPAIR REE = S73.0(3/hour (3 hours minimLWFACILETY) <br />= 5234.00 minimum S <br />RI TRANSFER FEE 2 520.00 <br />t <br />S <br />Cl CtiNSULTATION FEE = S73.00/hr <br />tMUTHORIZEO RELEASE EVAUATION : SM.00/hr <br />SAMPUNC INSPECTION EE <br />FOR OFFICE USE ONLY <br />SWEEPS 3 � COMPUTER 9 j�LOC CODE � GIST CME ( AMIXINT <br />S78.00/hr <br />5 <br />S <br />TDTAL OLIE S 'G1 3 7 LI)Q <br />CYEa 3/CASH I RECEIVED ST 1 DATE RECEIVED <br />