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12-01-1 7 3: 1 7Pb1 FROl1 - .. - - - _. --/- d -q -- - <br /> P. 2{ <br /> SAM Jd1q)IN OOUNT PUBLIC HEALTN SERVICES - ENVIRpOPNTAL REALTH DIVS101 /\ <br /> UNDERGROUND STORAGE TAXK PROGRAM - FES LaCSMEET J <br /> 5 FACILITY SITE NAME <br /> 1 FACILITY COM TACT NAME <br /> T <br /> E FACILITY ADDRESS 1714 9 <br /> )•"' SITE PHONE g Ni th AREA co"" �o y/All/o lero7C1TT STATE ZIP CCDE M of TANKS <br /> p S ro �� Cls at SITEP .1➢Pl1CANT/BILLIMO NAMEAPPLICANT CONTACT NAME <br /> IIC MRI11NG ADDRESSAPPLICANT PRONE N WITH AREA CODE <br /> ANT CITY F A STATE ZIP CODE <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 1986 1987 1988 1989 1990 <br /> A <br /> C xxxx XXXX RxXX XXXX x9xA S Kxxxxxx1 <br /> Tj FACILITT PENALTY FEES ASSESSED (If Aopticable) XXXX XXXX I XX7X I xxn xxxx S xxxxxxxx <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TAAK (After January 1, 1991) <br /> E <br /> M Tanks = 1987 1988 1989 1 1990 1 1991 1992 1993 1994 11995 1996 1997 <br /> F (mu(t(ply R by tee For <br /> A each year apolieab(a) KXXX XXXK 1(%XX X101% KXRX 1 <br /> t <br /> 11 TANK PENAL!T FEES ASSESSED xxxx I= %)OI% KKXX 70(x)( I S <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY s 518.50 11 <br /> 7 <br /> 1 M Tanks_ x 28,00 1988 through 1990 (156) 1991 through 1996 (SS6) 1997 <br /> SURCHARGE FOR 1997 X1 WXMMXXXXXXXXKXXXXX S <br /> C PERMANENT CLOSURE (Removal Or AuthoriteC ClOaurrin-place) TANK I.D. X(9) -Q <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours Minim VTANK)� i 0 TANK(s) X 1234,00 . !iiaq <br /> S <br /> U TEMPORARY CLOSURE (Plan Remiew = [napecTS dw:) <br /> R TANK I.D. g(s) <br /> E TEMPORARY CLOSURE FEE - 178,00/hour (3 hours minimum/FACILITY) 1234,DD Minimum S <br /> PI IMSTALUTION PIAN CHECK (Plan Ravi" 4 Construction InsvocTiont) FARC I.D. f(a) <br /> L <br /> A <br /> M PUN CHECK FEE 178.00/how (8 haura MiniamVYACILIT) = 262&,00 minimus 1 - <br /> R REPAIR FEE (Workplan Review E Comtruction Inape Tions) YANK I.D. N(a) <br /> E <br /> P TANK LJOING REPAIR FEE s 578,00/hour 13 h9WrS minimum/TANK) R TANK(s) X 5234,00 a S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 278.00/hour (3 hours min./FACILIT) = 1234.00 minimum 1 <br /> II <br /> PIPING REPAIR FEE = 278,00/hcuc (3 hours miniaaam/FAC1Li TY) = S234,DO NinimsM 1 <br /> M TRANSFER FEE • 220.00 UNAUTHORIZED RELEASE EVALUA110M - 2778.00/hr 1 <br /> 1 <br /> S <br /> C CONSVLIATICM FEE = 1178.00/hr SAMPLING INSPECTION FEE . 27H,00/hr I s <br /> 13RCK Fees, Iso o �r R�( � „ lfS � TOTAL DUE 1 00 <br /> FOR OFFICE USE ONLY <br /> SWEEPS 4 I COMPUTER N I LOC MOE DIST CGDE I ANCURT RECEIVED CHECK R/GSH RECEIVED EY I DATE RECEIVED 1 <br /> S <br /> EN 23 032 (REVISED 5.27.97) <br /> 4. <br />