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SAN .HNWX IN I' -'Y PUBLIC HEALTH SEAVIC=S - ENVIRONMENTAL ME'-1 DIVSION <br /> IAy` ..MOUND STORAGE TANK PROGRAN - FEE WORKSHEE. <br /> i <br /> S FA ILITT SITE E FACILITY CONTACT NAME <br /> I <br /> T .�. Ala <br /> E FACILITY ADDRESS SITE PHONE 0 Ntth AREA CODE <br /> i S . 9— <br /> CITY STATE ZIP CODE 1 0 of TANKS <br /> A <br /> P at SITE 3 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I �O <br /> I <br /> C MAILING AD ESS APPLICANT PHONE 0 W14 AREA CODE <br /> A ca o <br /> N <br /> T CITY STATE 21P CODETYPE of APPLICATION <br /> sure, InstaLLatien, etc.) C[ <br /> TOTAL <br /> 1986 1987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A LOCO( IDO(X I XXXX I )Oca )0= I S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AppliwhLe) XXXX I XXXX )0= I XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks 1987 11988 11989 11990 1991 1992 11993 1994 1995 11996 11997 <br /> F (multiply :oyoy fee for <br /> A each year apolica6le) XXXX I XXXX XXXX I X)= XXXX I I I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX I XXXX I XXXX IXXXX I I I S <br /> L <br /> ISTATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 Is <br /> T <br /> T x Tanks_ s 58.00 1988 through 1990 (S56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXX%XXXXX %XXXXXXXXXXXXXXXXXXXXXX S <br /> CPERMANENT CLOSURE (Resovai "or Authorized Closure-in-Place) TANK I.D. 0(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I x TANK(S)_,�k_ X 5234.00 = 5 O�� <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. 'W(s) ~V" ` <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. O(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimuP/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 s <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum 15 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimus S <br /> NJ TRANSFER Fe = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 13 <br /> I <br /> Si 1-- J— <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I I S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> _ <br /> c <br /> SWEEPS X I COMPUTER X LOC CODE I DIST CODE AMOUNT RECEIVED CHECK X/CASH RECEIVED BY DATE RECEIVED <br /> :._ s.._.__.. .._..._ ._ —......___....._ <br /> EN 23 032 (REVISED 5-27-97) <br />