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• EAN INTT PUBLIC NEALTN SERVICES - ENVIRONMENTAL WON DIVSIOII <br />tMERISROJOID STORAGE TANK PROGRAM - FEE UORKSHEET <br />i CILIT SITE NAME <br />.:ACUITY ADDRESS <br />�t <br />CITY <br />PPOLICAN /BILLING NAME <br />�C <br />1 <br />N5M1�1 l NG AOOR SS <br />T <br />FACILITY CONTACT NAME <br />SITE PHONE R with AREA CODE <br />STATE ZIP CODE A of TANKS <br />at SITE <br />APPLICANT CONWJ NAME <br />14 t( <br />APPLICANT PRONE 0 WITH AREA CODE <br />c(c- C,(- 3- <br />STATE ZIP CODETYPE of APPLICATION <br />-, Y l (Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Remove( or Authorized Closure -fn -Place) <br />TANK I.D. x(s) <br />1986 <br />1967 <br />1988 <br />1 1989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />TANK LININO REPAIR FEE * 178.00/hour (3 hours minimun/TANK) <br />S <br />PLAN CHECK FEE a 178.00/hour (8 hours minimum/FACILITY) = 5624.00 minimus <br />S <br />U <br />f AEY CLOSURE (Ptah Review A Inspections) <br />TANK I.D. a(s) <br />A <br />I <br />TANK RETROFIT REPAIR FEE * 178.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />S <br />R <br />E <br />TEMPORAAY CLOSURE FEE ® 1178.00/hour 0 hairs minimum/FACILITY) <br />1234.00 minimum <br />s <br />A <br />PIPING REPAIR FEE * 178.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />xxxx <br />XXXX <br />xxxx <br />XXXX <br />xxxx <br />S xxxxxxxx <br />C <br />T FACILITY PENALTY FEES ASSESSED (if Appticabte) <br />xxxx <br />xxxx <br />XXXX <br />xxxx <br />xxxx <br />S xxxxxxxx <br />t <br />v TANK FEE _ =50.00/TANK <br />(Prior to January 1,1991) <br />1170/TANK <br />(After <br />January 1, 1991) <br />E <br />N Tanks = <br />1988 1989 <br />1990 <br />1 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />F (muttiply +t by fee for <br />A each year apptieabte) <br />xxxx xxxxxxxx <br />xxxx <br />xxxx <br />s <br />C <br />I TANK PENALTY FEES ASSESSED <br />XXXX XXXX xxxx XXXXxxxx <br />S <br />L <br />ISTATE SURCHARGE FOR NEW FACILITIES ONLY=118.50 <br />E <br />T <br />I tanks x 18.00 <br />1988 through 1993 <br />(156) <br />1993 through <br />1947 <br />(S56) <br />1998 <br />1 <br />?SURCHARGE <br />xxxxxxxxxxxxXXXXXXXxxxxxxxx <br />xxxxxxxxxxxxxxxxxxxxxxx <br />1 S <br />FOR 1998 <br />C <br />PERMANENT CLOSURE (Remove( or Authorized Closure -fn -Place) <br />TANK I.D. x(s) <br />L <br />0 <br />CLOSURE FEE a $W.001hour (3 hours minimum/TANK) <br />N TANK(s) x = I S <br />A <br />P <br />TANK LININO REPAIR FEE * 178.00/hour (3 hours minimun/TANK) <br />S <br />PLAN CHECK FEE a 178.00/hour (8 hours minimum/FACILITY) = 5624.00 minimus <br />S <br />U <br />f AEY CLOSURE (Ptah Review A Inspections) <br />TANK I.D. a(s) <br />A <br />I <br />TANK RETROFIT REPAIR FEE * 178.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />S <br />R <br />E <br />TEMPORAAY CLOSURE FEE ® 1178.00/hour 0 hairs minimum/FACILITY) <br />1234.00 minimum <br />s <br />P <br />INSTALLATION PLAN CHECK (Plant Review 3 Construction Inspections) <br />TANK I.D. 0(s) <br />L <br />A <br />P <br />TANK LININO REPAIR FEE * 178.00/hour (3 hours minimun/TANK) <br />N <br />PLAN CHECK FEE a 178.00/hour (8 hours minimum/FACILITY) = 5624.00 minimus <br />S <br />R <br />REPAIR FEE (IMrkpten Review 3 Conetruction Inspections) <br />TANK I.D. R(s) <br />E <br />P <br />TANK LININO REPAIR FEE * 178.00/hour (3 hours minimun/TANK) <br />0 TANK(s) X 1234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE * 178.00/hour (3 hours min./FACILITY) = $234.00 minimus <br />S <br />R <br />PIPING REPAIR FEE * 178.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />S <br />N TRANSFER FEE * 120.00 <br />t <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FCR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION : 578.00/hr <br />SAMPLING INSPECTION FEE = 178.00/hr <br />I <br />TOTAL DUE ! f <br />EM 23 032 (REVISED 1.12-98) <br />