Laserfiche WebLink
fAM JOWIN MXTT PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> LIIDERfxOIIKD SrORAC,% TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> c� ��au•r,.tar� � . <br /> ACILITY ADDRESS SITE PHONE N with AREA CODE <br /> t <br /> Igo <br /> CITY STATE ZIP CODE N of TANKS <br /> A 90 at SITE <br /> P <br /> APPLICANT ILLING NAME APPLICANT CONTACTLNAME <br /> 11 R [ �• C, <br /> { A LING A S APPLICANT PRONE N WITH AREA CODE <br /> V-0— � l fp <br /> Al <br /> TI r TY STAdE ZTP CODE ��TYPEf APPLICATION y2�v -6ryr.r Nrco�� _ , 2rt, I ns i a l I a t Iani e t c-}c t./aM S 4trc At_r� <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • STOO.00 <br /> A xxxx xxxx xxxx xxxx XXXX S xxxxxxxx <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (If Appllcab(e) xxxx xxxx xxxx xxxx xxxx s XXXXXXXX <br /> 1 <br /> Y TANK FEE _ 150.00/TANK (mor to January 1,1991) $170/TANK (After January 1, 1991) <br /> i <br /> l tanks = 1488 1989 1990 1991 1992 1993 1994 19" 1996 1997 1998 <br /> F (muttipty N by fee for <br /> A each year appticsbla) kxxx xxxx XXXX Xxxx xxxx s <br /> { <br /> I <br /> TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxxx ,xxxx s <br /> t <br /> I STATE SURCHARGE FOR Meld FACILITIES ONLTSSl8.50 s <br /> T <br /> t Tenks it WOO 19M through 1993 ($56) 1993 through 1997 (S56) 1998 <br /> i' SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx 1 S <br /> C PEOMARENt CLOSURE (Refieva( Or Authorized Closure-in-Platte) TANK 1.11. x(s) <br /> L <br /> 0 CLOSIFRE FEE = 178.00/hour (3 hours minim:m/TANK) I TANK(s) x S234.00 S <br /> S <br /> U tt11POAAAY CLftJRE MM Review A InoWtfons) TANK I.D. 9(3) <br /> I <br /> E fEM WAY CLOSURE PEE a 178.00/hour (3 hours minion/FACILITY) $234.00 minimum s <br /> P INSTALLATION PLAN CHECK (Pier Review A Construction Inspections) TANK I.D. I)(s) <br /> L <br /> A <br /> A PUN CHECK FEE = 578.D0/hour (8 hours minimum/FACILITY) • $624.00 minimum S <br /> It REPAIR FEE (Uork0tArl Review A Construction Inspectlons) TANK I.D. ;(s) <br /> E <br /> P TANK LINING REPAIR FEE a 578.00/hour (3 hours minlmun/TANK) N TANK(s) x 5234.00 = S <br /> A <br /> I Wit RETROFIT REPAIR FEE a 5711.00/hour (3 hours min./FACILITY) = $234.00 minimum � S <br /> PIPING REPAIR FEE s $78.00/hour (3 hours m(nrmum/FACILITT) = %9=2W minimum <br /> R rRARSFER FEE a 120.00' UNAUTHORIZED RELEASE EVALUATION = 918,00/hr S <br /> C CC+f15ULTATION FEE : 578.00/fir SAMPLING INSPECTION 'FEE _ !78.00/hr 5 <br /> TOTAL DILE S �?a <br /> i OFFICE USE ONLY <br /> n i? u uu!rt .uu?a�ii��^i� iiia i <br /> SVEEPs s COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECETVEO <br /> .. ..rsr.1 <br /> mi! .a!n!ni!ea!¢¢ate:�Rn?san??�s-�t?!?n?s�r+r!a :nr.!ss�u�?7rr¢���c�'.?s� !a 4n:?�=!r�;- � <br /> aH 23 032 (REVISED 1.12-98) <br />