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!A!r JDMIN C01JMT7 P(IOLIC HEALTH SERVICES - ENVTRCa1M1ENTAL r1EALTH DIMON <br /> UMDER'NCI MO STORAGE TAM$ Pso6RAM FEE WORKSHEEY <br /> FACILITY SITE NAM FACILITY CCNCTACT NAM <br /> 4CILITY ADD RCS3SITE PHONE # with AREA CODE <br /> 76 <br /> C rT <br /> JaE VP CODE of TANKS '. <br /> A at SITE <br /> P <br /> AppLICAM BILLING NAME APPLICANT CONTA NAME <br /> I - <br /> C x INC ADO S � ArP�PL�IC�ANT PHONE 0 ITjjAREA CODE <br /> $ <br /> r Ci TTSTATE ZIP CO)E TYFE of APPLICATION <br /> (Closure, Inrsral(arion, etc. 1 <br /> TOTAL, <br /> 1986 1987 1984 1989 1990 <br /> ANNUM. FACILITY FEE (Prior to January 1, 1991) * 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S xxxxxxxx <br /> C <br /> I fACILIry PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX XXXX xxxx S xzxxxxxx <br /> I <br /> Y TANX FEE ■ 150,00/TANK ( r(or to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> A Tsnrs 1988 19x9 1990 1991 1992 1993 1994 1993 1996 1997 199E <br /> (Irulrlpiy 0 by fee for <br /> A ■■ch ye+r epp(leable) Uxx XXXX XXXx xxxx XXXX S <br /> C <br /> t TANK PENALTY FEES ASSIM0 xxxx XXXX xxxx xxxx XXXX S <br /> L <br /> STATE SUACNAACE FOR NEN FACILITIES ONLY■318.50 s <br /> T <br /> I rink$ x WOO 1988 through 1993 (156) 1993 through 1997 (356) 1998 <br /> 7 <br /> SURCHAAGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX IS <br /> c PEA1(ANENr CLOSURE (A&MVel or Authorized Closure-In-Place) TANK I.D. #(s) <br /> L <br /> 0 CLM AE FEE + 178,00/h" (3 hours minlroWTANK) # TANK(s) X 5234,00 s S <br /> 1 <br /> U FE700l.AJIY Ci,?3Af (PIeA Review i Inspectlons) TANK I.D. #(s) <br /> R <br /> E TEJI"A1RY CL4 VII !EE + 578,00/hour (3 hours minimum/FACILITY) 5234,00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review 9 Constructlon Inspections) TANK I.D. #(s) <br /> — <br /> L <br /> A <br /> $ PLAX CMECX FEE s 578.00/hour (8 hours iolni"/fACILITT) ■ 5624.00 MiniauN S <br /> I IEPA(k FEE (workplan Review A Corratructiorl Inspections) TANK I.D. #(s) <br /> E <br /> P TAMC LININQ REPO FEE s ST8.00/hour (3 hours minimum/TANK) # rANK(s) X 5234.00 ■ 5 <br /> A <br /> I WC 11ETAOFIT REPAIR FEE * DO/hour 0 hours min,/FACILITY) + �inirn.m <br /> I <br /> PIPING IEPAIR FEE + 578,00/hour (3 hours minimum/FACILITY) • 5234.00 minle+.sn S <br /> N rRANSFER FEE + 524.00` UNAUTHORIZED RELEASE EVALUATION + S78i00/hr S <br /> I <br /> S � _ <br /> C coi rATION FEE + S78,00/hr SAMPLINO INSPECTION FEE578,40/hr s <br /> TOTAL DUE S <br /> FCA OFFICE LME OIILY ! <br /> I I?IMPuW111WW1! ItlWNutl un {{''qq��II"I d!H: <br /> iF>r 1 I J. 1 dl i 4Fii„{[!plli Nll114!I!'d'.I!II!M! it II I.A.ui <br /> WEEP1 9 COMPUTER # LOC CODE 01ST CCCE AMOUNT RECEIVED CHECK #/CASH RECEIVED By OArE RECEIVED <br /> I <br /> S <br /> m rHF9C91'WRS'*1^I3'1ri¢1 I l!I0 <br /> YC FE�'T.��-."_. <br /> ==H[Up. .IllRli 1@f11II1 S[io1im HHAin SAiF1, M i= ISI if D�IIiIiII 41�i 111'sau7;,rr¢..�,.rs:.�.._' <br /> rN 23 032 (AEYISED 1.12.98) <br />