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JAN IM MISM PtXLIC HEALTN SERVICES - EUVIRONMTALRTN 01MON <br />UNDOMW STORM TANK FEB WRKSHEIET <br />c <br />FACILITY-tiTE NAME <br />4 ® s <br />L <br />FAC CONTACT NAME <br />► <br />TOTAL <br />ANNUAL FACILITY FEE (Prior to Jaxury 1p 1991) a $100.00 <br />A <br />0 <br />1986 <br />.:ACILITY ADDRESS <br />1988 <br />SITE PHONE 0 with AREA CODE <br />1990 <br />iC <br />f S <br />XXXX <br />A <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />A <br />C T/ <br />( rior to January 1,1991) <br />ST TE <br />ZIP CODE <br />a of YANKS <br />at SITE <br />D <br />E <br />I Tanks <br />F (multiply 1-1;7—foo for <br />A each year appliesble) <br />1988 1989 <br />XXXX xxxx <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 <br />D <br />L <br />APPLICAN LLINO NAME <br />1998 <br />APPLICANT CONTIPf& NAME <br />I <br />\ <br />C <br />A <br />MAILING A RESS <br />xxxx xxxx <br />xxxx xxxx xxxx <br />APPLICANT PRONE.04tTill AREA CODE <br />R <br />s <br />L <br />I STATE SURCHARGE FOR NEW FACILITIES ONLY418.50 <br />T <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Instatlation, etc.) <br />c <br />PERMANENT CLOSURE (R at or Authorized Closure -in -Place) <br />TANK I.D. x(s) <br />L <br />► <br />TOTAL <br />ANNUAL FACILITY FEE (Prior to Jaxury 1p 1991) a $100.00 <br />A <br />0 <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />U <br />XXXX XXXX XXXX XXXX <br />XXXX <br />S xXxxxxxx <br />C <br />T FACILITY PENALTY FEES ASSESSED (It Appllcsbte) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />s xxxxxxxx <br />I <br />Y TANK FEE = 150.00/TANK <br />( rior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />E <br />I Tanks <br />F (multiply 1-1;7—foo for <br />A each year appliesble) <br />1988 1989 <br />XXXX xxxx <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />XXXX XXXX XXXX <br />S <br />C <br />I TANK PENALTY FEES ASSESSED <br />xxxx xxxx <br />xxxx xxxx xxxx <br />s <br />L <br />I STATE SURCHARGE FOR NEW FACILITIES ONLY418.50 <br />T <br />S <br />I Tanks it 58.00 <br />i'. SURCHARGE FOR I"ll <br />1988 through 1993 (556) <br />1993 through 1997 (S56) <br />1998 <br />I <br />xxxxxxxxxxxxxXXXXXXXxxxxxxx <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />c <br />PERMANENT CLOSURE (R at or Authorized Closure -in -Place) <br />TANK I.D. x(s) <br />L <br />► <br />TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/TANK) <br />A TANK(s) X $234.00 s <br />0 <br />CLOSURE FEE A 178.00/haw (3 hours minfmWTANK) <br />1 TANK(s)X S234.00 a I s <br />I <br />U <br />t Y CtftXl MIA ISO & i Intpectlons) <br />TANK I.D. S(s) <br />R <br />` <br />E <br />PAAY CLOSURE FEE ® 578.00/hour (3 hours miniaasn/FACILITY) <br />$234.00 minimus <br />S <br />P INSTALLATION PUN CHECK (Platt Review 9 CoMtructlon tnspectlons) TANK I.D. s(s) <br />L <br />A <br />R PLAN CHECK FEE a 578.00/hour (8 hours minimun/FACILITY) • $624.00 miniS <br />R <br />REPAIR FEE (WOrkPtsm R WPew i Construction Inspections) <br />TANK I.D. 4(s) <br />E <br />► <br />TANK LINING REPAIR FEE a 578.00/hour (3 hours minimum/TANK) <br />A TANK(s) X $234.00 s <br />S <br />A <br />I <br />MIX RETROFIT REPAIR FEE a our (3 hours min./FACILITY) • inimtm <br />S• <br />R <br />` <br />►IPING REPAIR FEE a $78.00/hour (3 hours minimun/FACILITY) • $234.00 minimum <br />S <br />N TRANSFER FEE a S20.00 UNAUTHORIZED RELEASE EVALUAT(011 a S78t00/hr <br />1 <br />S <br />C CONSULTATION FEE a $78.00/hr SAMPLING INSPECTION FEE a 178.00/hr <br />Ft'R OFFICE USE ONLY <br />n i <br />SWEEPS x COMPUTER 0 LOC CODE 01ST CODE AMOUNT RECEIVEOCHECK RI/CASH <br />5 <br />Ea 23 032 (REVISED 1.12.98) <br />H <br />w�„tuu,mmmau�mm��m mu.a,�m..n <br />DATE RECEIVED <br />i <br />