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Si FACILITY SITE NAME <br />Loi?, =`A N -Z i ®i .i V i L. t'K <br />T� SITE PHONE S with AREA CCOE <br />E FACILITY ADORE— <br />QOR£SSCITY(STE! <br />TRANSFER FEE = 520.00 p <br />1986 p 1987 p 1488 p 1484 <br />j 1490 <br />C: TY <br />I <br />ZIP CODE ® 4 <br />� ! at SITE <br />AI <br />AI <br />SAMPLING INSPECTION F-..=_ = 578.00/hr <br />0 <br />APP! ICANTr8i4+•tu6-+MIME ,,:qz / ez <br />L � �>d I.TG /'.� EKI llv - <br />II�c , <br />C <br />T <br />APPLICANT CONTACT NAME -1P <br />M : �G LEE 1 &T f O / 5 Ji <br />I <br />Cl MAILING AOORESS <br />=cc s <br />APPLICANT PHONE x (LITH AREA CCOE <br />Al p,®91.1 <br />5170/TAMC (Aster January t, <br />1441) <br />CITY <br />T� w <br />J 1 5l ; F ` �,�. , ` . ` -/-j <br />� Tanks = �_p 11986j 1487 p 1988 p 1484 p 1490 <br />STATEI <br />I <br />ZIP CODE p TYPE of APPLICATION <br />(Clasure, Installation, etc.) <br />Mj <br />TRANSFER FEE = 520.00 p <br />1986 p 1987 p 1488 p 1484 <br />j 1490 <br />t <br />S. <br />Cl <br />ANNUAL FACILITY Fc -=-(Prior to January 1, 1991) = $100.00 <br />= x p =cx p xxxx p xxxx <br />pxxxx S <br />AI <br />SAMPLING INSPECTION F-..=_ = 578.00/hr <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (It Applicable) <br />p xxxx xxxx p xxxx p =cc <br />=cc s <br />I, <br />V1 <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TAMC (Aster January t, <br />1441) <br />£; <br />� Tanks = �_p 11986j 1487 p 1988 p 1484 p 1490 <br />1441 p 1992 p ,44'3 p 1994 p 1495 <br />jj 1997 <br />F! <br />F. <br />Al <br />(.-ultiply x a�y ee for <br />each year applicable) p xxxx p )0= p xxxx (xxxx p xxxx <br />p p p <br />! -76 S (o SO <br />Ij <br />TANK PENALrY FEES ASSESSED p xxxx j xxxx j xxxx p xxxx 1 xxxx <br />p t j ` <br />p S <br />I <br />i STATE SURCHARGE = S $.00/TANK <br />Y <br />j $ FAC ILily?�- <br />� <br />p <br />C; PERMANEXT CL --SURE (Removal or Authorized Ciosure-in-PLace) <br />TANK I.D. +(s) <br />L: <br />01 <br />CLOSURE FEE = 578.00/hour (3 'hours minimum/TANK) p= <br />S TANK(s) x SZ34.00 <br />p S <br />S. <br />UI <br />T::4PCRARY CLOSURE (?Lan Review 3 Insoec:ions) 4 <br />TANK I.D. l(s) <br />R; <br />E( <br />TEMPORARY CLOSURE F -e: = 578.001hour (3 hours minimum/FACILITY) p <br />5234.00 mini <br />S <br />P! INSTALLA+'ICN PLAN CHECK (Plan Review b Construction Inspections) <br />TANK t.D. 9(s) i, 2, 3,`i' <br />L: <br />A <br />S �. G A <br />Nl <br />PLAN CHECK F'c_ = 578.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minimum <br />R} <br />REPAIR FEE (Workplan Review b Construction inspection) p <br />TANK I.D. #(s) <br />E, <br />P1 <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />0 TANKCs) x 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minim= <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimum <br />S <br />Mj <br />TRANSFER FEE = 520.00 p <br />UNAUTHORIZED RELEASE EVALUATION s 578.00/hr p <br />( S <br />t <br />S. <br />Cl <br />I <br />i <br />CONSULTATION FEE = 578.001hr ( p <br />SAMPLING INSPECTION F-..=_ = 578.00/hr <br />S <br />TOTAL DUE S 135'+. S� <br />FM OFFICE USE CULT <br />SLiEEPS ` CCr1PUTER x I LOC CCOE <br />T3 <br />OAST CODE I AMOUNT RECEIVED I CHECK &/GASH I <br />RECEIVED 37 DATE RECEIVED <br />u <br />' <br />I � <br />► I I <br />! S <br />REVISED : 03 3'vrJF 191 <br />r <br />