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FAC LI1 SITE NAME <br />ACIIITI AOORIS$ <br />61 <br />CI TT <br />A <br />v <br />ADPL CANT ILLINO NAME <br />I <br />C LINO A SS <br />SAM JM WIM MXT7 PLISL)C NEALTN SERVICES - ENViRONF1ENTAL HEALTH DiVSION <br />UMOaftaIso STORAGE TAXK PROGRAJN - FES UORKSHEET <br />'FACILITY CONTACT NAME <br />KRA <br />SITE PHONE f with AREA CODE <br />2(n - 3 <br />4;�E Z P CODE 0 of TANKS <br />- <M O at $I TIE <br />I APPLICANT CONTACT NAME <br />APPLICANT PHONE M WITH AREA CODE <br />z6q— -116X33 <br />ST IE �ZIPCDOE TYPE of APPLICATION <br />J( ✓ (Closure, Im tallat(on, etc.) <br />TOTAL <br />C <br />L <br />1986 <br />1987 <br />1 1984 <br />1989 <br />1 1990 <br />U <br />R <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) • S100.00 <br />TANK I.D. !(s) <br />E <br />fE)"AAY CLOSURE PEE a !78.00/hour 0 hours miniaLan/FACILiTY) <br />5236,00 minimus <br />s <br />xxxx <br />XXXx <br />XXXX <br />xxxx <br />xxxx <br />S xxxxxxxx <br />A <br />C <br />r FACILITY PENALTY FEES ASSESSED (if Applicable) <br />I <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />s xxxxxxxx <br />y TANK FEE 550.00/TANK ( rior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />PIPING REPAIR FEE a ST8.DO/hour (3 hours a tlnimuWFACILiTYf,F1 mInIn n <br />t <br />RI ftAXSFER FEE a $20.00 <br />I <br />A Tanks ■ <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1996 <br />1995 <br />1996 <br />1997 <br />1998 <br />F Onuttlply 0 by fee for <br />kxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S <br />A each year applicable) <br />C <br />I TANK PENALTY FEES ASSESSEo <br />L <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />s <br />STATE SURCHAAGE FOR NEW FACILITIES ONLY+518.50 <br />T <br />S <br />S tanks x 58.00 <br />1988 through 1993 (S56) <br />1993 through 1997 (S56) <br />1998 <br />xxxxxxxxxxxxxxxxxxxxxxxxxxx <br />zxxxxxxxxxxxxxxxxxxxxxx <br />I s <br />SURCHARGE FOR 1998 <br />C <br />L <br />PEAXANEXT CLOSURE (Remova( or Authorized Closure -fn -Place) <br />TANK I.D. f(s) <br />0 <br />7 <br />CLOSURE FEE a 578.00/hour (3 hour minfain/TANK) <br />M TANK(s) x SZ36.00 a I s <br />U <br />R <br />TEJIPCRAUlY CL03URE (Pl1A R/viiw i lnsptetims) <br />TANK I.D. !(s) <br />E <br />fE)"AAY CLOSURE PEE a !78.00/hour 0 hours miniaLan/FACILiTY) <br />5236,00 minimus <br />s <br />►, IxSTALLATION PLAN CHECS: (Plan Review 9 Construction Inspections) <br />L' <br />TANK I.D. x(3) <br />A <br />s PLAx CAM FEE 578.00/hour (8 hours mini "/FACILITY) 5626.00 mini" <br />S <br />R <br />E <br />REPAIA FEE (Workplan Rfvltw i Construction Inspections) <br />TANK I.D. f(s) <br />P <br />A <br />rkXx LINING REPO FEE + 578.00/hour (3 hours minimum/TANK) <br />/ TANK(s) X 5234.00 ■ <br />S <br />I <br />Wr RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) S236.00 minimal" <br />s <br />PIPING REPAIR FEE a ST8.DO/hour (3 hours a tlnimuWFACILiTYf,F1 mInIn n <br />S 6 7,0jJ <br />RI ftAXSFER FEE a $20.00 <br />I <br />UNAUTHORIZED RELEASE EVALUATION a S7& 00/hr <br />S <br />s <br />I <br />CI CCASULrATIOW FEE a 578.00/hr <br />SAMPLING INSPECTION FEE • ST8.00/hr <br />S <br />FCR Of F l CE USE ONLY <br />T.+EEP3 s I CCM(PUT!R 1 I LOC CODE <br />EM Z3 032 (REVISED 1 12 98) <br />OIST.CCOE AMOUNT RECEIVED CHECK f/CASH <br />S <br />TOTAL DUE s �>� 00 i <br />'ill! nIN INBI!il!I!I I!!I!IiI IIIIIP ai IIP , <br />RECEIVED By DATE RECEIVED <br />i <br />1� !s[u3rttmtrroo--r!!en!!n!, I!enamc:!?; <br />Y1YOp @�HIY il14:�dii Qili:!ik'. cliiii F.ic i::: a!Eili!::::?!: .: . <br />