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F FACILITY/SITE NAME <br />A <br />C <br />I <br />L STREET ADDRESS <br />r—_ -r <br />IY CITY <br />Loo <br />AAPPLICANT/BILLING NAME <br />P <br />Llj �hII <br />I MAILING ADDRESS <br />A <br />N CITY <br />T I roll...-- I- ( A <br />Qn14 AwU 1 tv LUCAL HEALTH D I R I CT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br />FACILITY CONTACT NAME <br />FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br />E. L. PHILLIPS CONSULTING, INC. <br />PHONE (602) 453-7802 <br />P. O. BOX 1146 <br />LAKE HAVASU CITY, AZ 86403 <br />Pay to the <br />order of <br />rm f First Interstate Bann of Arizona, N.A. <br />Lake Havasu City Office 142 <br />P.4 kiftmbifft 1601 McCulloch vivo. <br />Bank Lake Havasu City, Arizona 86403 <br />SITE PHONE I WITH AREA CODE <br />STAT ,ZIP CODE EloT TanksSite <br />APPLICANT CONTACT NAME <br />APPLLTPHONE I WITH AREA C00E <br />STATE IIP CODE AP�� BTALLAiI ETC. p <br />.I ..__TOTAL <br />4538 <br /> <br />19 <br />/4 <br />= Dollars <br />for <br /> <br /> : <br />I tnruKnfcr t,Luau><t r l:c = >adu, uv earn I ft,iK ` - �"— <br />I i IdUK� _ A ?OV.VV <br />IP PLAN CHECK (Installation or Repair) <br />L �E <br />�YN�..NT <br />A ___ __ E C E l V <br />N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />REPAIR <br />E TANK REPAIR FEE _ $110.00 each TANK <br />P _ __.-_..—PFA, <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />I _ <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION —�— <br />(when applicable) (when applicable) SAMPLING INSPECTION <br />_ __ (when applicable) <br />FEE = $30.00/hr " a -- I <br />FEE FEE _ $35.00/hrl� <br />OFFICE USE ONLY <br />TOTAL DUE <br />s <br />EMUM <br />SWEEPS i COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK CASH RCVD BY DATE NRECEIVED I RMITIIGIV' <br />9�( y (�..._.__.. <br />4411 �crT� _z� ...... <br />.`�.__.._. <br />IRiI� IIIIUIIIIIIIINiIVD►4ulullalil cnulli .S S `7'Z/ /�/�"7 <br />UNIII IuliLl7NgI1IH1p u1tN1111iuudunnmuuuiaxm.xm.x...._ :-- <br />