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` SAM JCIW111 COW? PUQLIC HEALTN SERVICES - ENVIRONN"TAL HEALTH DIVSION <br />W060CM STORAGE TANK PROGRAM - FEE UORKSHEET <br />TOTAL <br />FACILL�II^TTTSITE NAME <br />1986 <br />1987 <br />FACILITY CONTACT NAME <br />1989 <br />1990 <br />CLOTURE FEE a !78.00/1iour (3 hours minfaWTANK) <br />ANNUAL FACILITY FEE (Prior to January In 1991) • $100.00 <br />I s <br />3 <br />.;ACILITY ADDRESS <br />--�- <br />V A3 <br />S <br />SITE PHONE I with AREA CODE <br />4124 <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />A <br />A <br />S <br />JCI STATEtZP <br />, <br />CODE1 <br />ui Z <br />of TANKS <br />at SITE <br />P <br />C <br />P <br />L <br />APD /BILLING NAME <br />�, <br />APPLICANT CONTAC E <br />I <br />q. <br />xxxx <br />S xxxxxxxx <br />i <br />Y TANK FEE = 530.00/TANK ( rfor to January 1,1991) <br />C <br />x A00 SS � � <br />APPLICANT PRONE N WITH AREA CODE <br />E <br />11 Tanks • <br />�LINC <br />c <br />1989 <br />1990 <br />1991 <br />T <br />CI <br />1994 <br />STATE <br />ZIP CODE <br />TYPE oP APPLICATION <br />1998 <br />F (Tultipiy a by feo for <br />SZof <br />(Closure, Installation, ecc.) <br />TOTAL <br />PERMANExt CLOSURE (Removal or Authorfted Ctosure-In-Place) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />CLOTURE FEE a !78.00/1iour (3 hours minfaWTANK) <br />ANNUAL FACILITY FEE (Prior to January In 1991) • $100.00 <br />I s <br />3 <br />TANK LINING REPAIA FEE ® !78.00/hour (3 hours minim m/TANK) <br />0 rANK(s) X (234.00 = <br />S <br />U <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />A <br />5234.00 minimum <br />S <br />C <br />r FACILITY PENALTY FEES ASSESSED (it Appt(cabts) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />i <br />Y TANK FEE = 530.00/TANK ( rfor to January 1,1991) <br />1170/TANK (After January 1, 1991) <br />E <br />11 Tanks • <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />F (Tultipiy a by feo for <br />xxxx <br />xxxx <br />XXXX <br />xxxx <br />XXXX <br />S <br />A each year applicable) <br />C <br />1 TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />xXXX <br />XXXX <br />S <br />L <br />I STATE SURCHARGE FOR NEV FACILITIES ONLY416.50 <br />S <br />Ti <br />I tanks x 58.00 <br />1988 through 1993 ($56) <br />1993 through 1997 (S56) <br />1998 <br />xxxxxxxxxxxxxxxxxxxxxxxxxxx <br />xxxxxxxxxxxxxxxxxxxxxxx <br />l S <br />i' SURCHARGE FOR 1996 <br />C <br />PERMANExt CLOSURE (Removal or Authorfted Ctosure-In-Place) <br />TANK I.O. x(s) <br />L <br />PLAN CHECK SEE • $78.00/ham (8 hours mfH4"/FACILITY) • S624.00 minimum <br />$ <br />0 <br />CLOTURE FEE a !78.00/1iour (3 hours minfaWTANK) <br />0 TANK(s) X 5234.00 <br />I s <br />3 <br />TANK LINING REPAIA FEE ® !78.00/hour (3 hours minim m/TANK) <br />0 rANK(s) X (234.00 = <br />S <br />U <br />tM$CRAAY CL03UR11 MAA Review i Inspections) <br />TANK I.O. S(s) <br />R <br />PIPING REPAIR FEE a .DO/hour 0 hours mfnfmum/FACILIIT) a inseam $ 7— >Y <br />8 <br />E <br />tE?"AAY CLOSURE SEE 0 578.00/hour (3 hours mfnfaRWFACILITY) <br />5234.00 minimum <br />S <br />P <br />L <br />INStALLATION PLAN CHECK (Plan Review 9 Construction Inspections) <br />TANK I.D. I(s) <br />A <br />R <br />PLAN CHECK SEE • $78.00/ham (8 hours mfH4"/FACILITY) • S624.00 minimum <br />$ <br />I <br />E <br />WAIA FEE (Vorkptsn Review t Construction Inspections) <br />TANK I.D. 1(s) <br />P <br />A <br />TANK LINING REPAIA FEE ® !78.00/hour (3 hours minim m/TANK) <br />0 rANK(s) X (234.00 = <br />S <br />I <br />R <br />tAXX RETROFIT REPAIR FEE a S78.00/hour (3 hours min./FACILITY) • $234.00 minfmum <br />S <br />PIPING REPAIR FEE a .DO/hour 0 hours mfnfmum/FACILIIT) a inseam $ 7— >Y <br />8 <br />N TRAXSFEA FEE a 120.00 UNAUTHORIZED RELEASE EVALUATION a $7&00/hr <br />I <br />C COMLrATION FEE a 578.00/hr SAMPLING INSPECTION FEE a !78.00/hr <br />FCX OFFICE USE ONLY <br />SVEEDS ! COMPUTER / LOC CODE 01ST COOS AMOUNT RECEIVED CHECK I/CASH <br />f <br />" 11 <br />S <br />TOTAL DUE [$7-4 7®otJ <br />r!!19! !i7mN <br />u v ulnaMIae i )! I" <br />irtunuea <br />RECEIVED BY GATE RECEIVED <br />