Laserfiche WebLink
U111 JCIA+dUiN PUeLDC NEALTN SERVICES - ENVItORMENTAL HEALTH DIVSION <br />LN11I)C UM STORAGE TANK PROGRAM - FEE UORKSHEET <br />FACILITY SITE NAME FACILITY CONTACT AME <br />:ACILIIT AGGRESS SITE PHONE M with AREA CODE <br />CI STATEl ZIP CODE R of TANKS <br />AS7 "zk1 at SITE <br />P <br />PAPP /8ILLING NAME APPLICANT CONTAC E <br />el airC AONLINO AD0j&SSAPPLICANT PRONE N 4 AREA CODE <br />A /V'� 1/� <br />e <br />1 C STATE ZIP CODE t I TYPE of APPLICATION <br />?Szo (Closure, Installation, etc.) <br />TOTAL <br />PEWNENt CLOSURE (Removal or Authorized Closure -fn -Place) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) a !100.00 <br />0 <br />CLOSURE FEE a !78.00/hour (3 hours minfmum/TANK) <br />S TANK(s) X 5236.00 I s <br />S <br />PLAN CRICK FEE a 178.00/hour (8 hours mfnTmw/FACILITY) 1624.00 minimum <br />s <br />XXXX <br />xxxx <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />A <br />ARY CLbstfRE BEE ® 111178.00/hour (3 hours minimLsn/FACILITT) <br />$236.00 mfnfmm <br />s <br />C <br />r FACILITY PENALTY FEES ASSESSED (if Applicable) <br />xxxx <br />xxxx <br />XXXX <br />XXXX <br />xxxx <br />S XXXXXXXX <br />I <br />Y TANK FEE 150.00/TANK ( rfor to January 1,1991) <br />!170/TANK (After January 1, 1991) <br />E <br />0 Tanks • <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1493 <br />1996 <br />1995 <br />1 1996 <br />1997 <br />1998 <br />F (multiply R by fet for <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />s <br />A each year apQlleabla) <br />C <br />I TANK PENALTY FEES AWSSEO <br />xxxx <br />xxxx <br />XXXX <br />xxxx <br />XXXX <br />s <br />L <br />1 STATE SURCHARGE FOR REV FACILITIES ONLY418.50 <br />S <br />T <br />I tanks x 58.00 <br />1988 through 1993 (S56) <br />1993 through 1997 ($56) <br />1998 <br />I <br />v <br />xxxxxxxxxxxxxxXXXXXXxxxxxxx <br />XXXXXXXXXXXXxxxxxxxxxxx <br />1 S <br />SURCHARGE FOR 1998 <br />C <br />PEWNENt CLOSURE (Removal or Authorized Closure -fn -Place) <br />TANK t.D. x(s) <br />L <br />E <br />P <br />0 <br />CLOSURE FEE a !78.00/hour (3 hours minfmum/TANK) <br />S TANK(s) X 5236.00 I s <br />S <br />PLAN CRICK FEE a 178.00/hour (8 hours mfnTmw/FACILITY) 1624.00 minimum <br />s <br />V <br />tEAPOWY CtftXl (PISA Rwidu & Inspection) <br />TANK I.D. S(s) <br />R <br />I <br />ARY CLbstfRE BEE ® 111178.00/hour (3 hours minimLsn/FACILITT) <br />$236.00 mfnfmm <br />s <br />P <br />INSTALLATION PLAN CHECK (Platt Review 9 Construction Inspections) <br />TANK I.O. As) <br />L <br />E <br />P <br />A <br />M TANK(s) X !236.00 • <br />S <br />s <br />PLAN CRICK FEE a 178.00/hour (8 hours mfnTmw/FACILITY) 1624.00 minimum <br />s <br />t <br />REPAIR FEE (Workplan Rlvfew i Construction Inspectlons) :• <br />TANK 1.0, t(s) <br />E <br />P <br />TAU LINING REPAIR FEE + !78.00/hour (3 hours minimum/TANK) <br />M TANK(s) X !236.00 • <br />S <br />A <br />I <br />tANx RETROFIT REPAIR FEE • l78.00/hour (3 hours min./FACILITY) * S234.00 m(nimtrn <br />s <br />PIPING REPAIR FEE • .00/hour (3 hours minimun>IFACII(TT) • inlNam <br />s <br />e <br />A TRANSFER FEE a 120.04 UNAUTHORIZED RELEASE EVALUATION a S78t00/hr <br />I <br />4 <br />C CONSULrATION FEE s !78.00/hr SAMPLING INSPECTION FEE x !78.00/hr <br />FCR OFFICE M ONLY <br />II s <br />MEDS I COMPUTER / LOC COME GIST CODE AIIMUNT RECEIVED*• CHECK S/CASH <br />S <br />1. w 1$ <br />TOTAL DUE S 7,6 7r o� <br />n i '•;r� wn� t •rtiiuu�nr:;;uuea <br />RECEIVED By PATE RECEIVED <br />