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5ANJMWIN COUNT? PUSLlC HEALTH SERVICES • ENVIRONMENTAL WEALTH OIVSiON <br />UNDUOMM STORAGE TANK PROGRAM • FES WORKSHEET <br />FACILITY SITE NAME FACILITY Cpl T NAME <br />a <br />ACIIITY OORESS SITE PHONE 1 with AREA CODE <br />p <br />te� <br />7 STATE ZIP CODE 0 of TANKS <br />A at SITE <br />v <br />ADDIICA LING NAME APPLICANT CONTACTAL <br />N E <br />L 4� i41 <br />I <br />CAILING AO ON <br />SS APPLICANT PHONE 0 WITH AREA CODE <br />Al <br />A <br />1 CI �aE[ZIP CODE ' TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to JwvAry 1, 1991) a $100.00 <br />1986 <br />1967 <br />1984 <br />1989 <br />1990 <br />TANK LININO REPAIR FEE a 578.00/hour (3 hours minim(m/TANK) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />f <br />I <br />FACILITY PENALTY FEES ASSESSED (if Appticable) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />Y <br />E <br />fANK FEE • 550.00/TANK ( rior to January 1,1991) <br />5170/TANK (After Janu'sry 1, 1991) <br />F <br />A <br />C <br />t Tanks • <br />(avttlpty / try ,Pee for <br />each year spptlesbte) <br />1988 1989 1990 1991 <br />1992 <br />1993 <br />1996 1995 <br />1946 <br />1997 <br />1998 <br />xxxx XXXX xxxx xxxx <br />xxxx <br />s <br />I <br />l <br />TANK PENALTY FEES ASSESSED <br />xxxx xxxx xxxx xxxx <br />xxxx <br />g <br />I <br />1 <br />STATE SURCHARGE FOR NEW FACILITIES ONLYW 8.50 <br />S <br />I Tanks x 58.00 <br />v <br />SURCHARGE FOR 1998 <br />1988 through 1993 (256) <br />1993 through 1997 (S56) <br />1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXxxxxxxxxxxx <br />, S <br />C <br />l <br />PEPANEXT CLOSURE (ReN vel or Authorized Closurc•ln•Ptace) <br />TANK I.O. x(s) <br />0 <br />S <br />CLOTURE FEE a 578.00/hour (3 hours minim WTANK) <br />0 TANK(s) X S236.00 a S <br />U <br />t <br />tMPOWY CLftM (MIA RNwiew i Inspections) <br />TANK I.D. 0(s) i <br />t <br />TE?"ARY CLOSURI 1EE 6 578.00/hour (3 hours minlmsaR/FACtItTY) <br />$236.00 minimum <br />s <br />P <br />L <br />INSTALLATIOM PLAN CHECK (Plan Review i Construction Inspections) <br />TANK I.D. 0(s) <br />A <br />A <br />PLAm CHECK FEE • 578.00/hour (8 hours Imi61mum/FACILITY) • S626.00 minlmsm <br />S <br />R <br />REPAIR FEE (WOrkpien Review It Construction inspections) <br />TANK I.D. 1(s) <br />E <br />P <br />TANK LININO REPAIR FEE a 578.00/hour (3 hours minim(m/TANK) <br />N TANK(s) X 5234.00 e <br />$ <br />A <br />I <br />WX RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) <br />• $236.00 minimum <br />R <br />PIPING REPAIR FEE a 578.00/hour (3 hours minimun/FACILITY) <br />. S236.00 minlmum S <br />X TRAXSFEA FEE a 520.00` UNAUTHORIZED RELEASE EVALUATION a SM 00/hr <br />l <br />S - <br />C CCASULTATIOW FEE a 578.00/hr SAMPLINO INSPECTION FEE a 578.00/hr <br />Fri Of F 1 CE USE CULT <br />II $ I <br />$ <br />TOTAL DUE_ 1S <br />MIPS ! COMPUTER t LOC CODE I OIST,CCOE AMOUNT RECEIVED CHECK N/CASH RECEIVED AY <br />S <br />fx 23 032 (REYISED 1 12 98) <br />DATE RECEIVED <br />'i <br />u�tu<er.:ii,i <br />