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SAM JON1(RIiN COLNITT PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEIILld DIVSION <br /> UNDEROMM STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY slit NAME FACILITY CONTACT NAME <br /> :ACILITY ADDRESS SiTE PHONE R with AREA Con <br /> e <br /> CITY STATE ?.(P CODE +1 of TANKS <br /> A f3 I. `S��5 et SITE <br /> P p► ILLING NAME APPLICANT CONTACT NAME <br /> / <br /> APPLICANT PHONE R WIN AREA CODE <br /> C tiAjLING AD RESS J _ <br /> M <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, instettation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Apptfcable) XXXX xxxx XXXX xxxx xxxx S xxxxxxxx <br /> I <br /> V TANK FEE 150.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> N Tanks 1988 1989 1990 11991 1992 1993 1994 1995 1996 1997 1998 <br /> F (muttipty R by fee for <br /> A each year applicab(e) xxxx XXXX xxxx xxxx xxxx s <br /> C <br /> 1 TANK PENALTY FEE! ASSESSED xxxx xxxx XXXX XXXX Ixxxx S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-S18.50 > <br /> T I <br /> S tanks )t $8.00 19$8 through 1993 (556) 1993 through 1997 (S56) 1998 <br /> ?SURCHARGE FOR 1998 XXXXXXxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx l S <br /> c PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. s(s) <br /> L <br /> 0 CLOSURE FEE • !78.00/hour (3 hours minimum/TANK) N TANK(s) X SZ34.00 I s <br /> I <br /> U tEJRPORAAY CtOSURf (Ptt$A Review t Inspectims) TANK I.D. X(s) <br /> R <br /> E TEMPORARY CLOTURE FEE • ljff00/hour (3 hours mfnisun/FACILITY) $234.00 minimus $ <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Constructlon tnspections) TANK t.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE • 1178.00/hour (8 hours mfnfmun/FACILtTY) 5624.00 minimus TS <br /> R REPAIR FEE (Norkptan Rfvifv & Construction inspectlons) TANK I.D. R(s) <br /> E <br /> P LANK LININO REPAIR FEE • 178.00/hour (3 hours minimus/TANK) 0 TANK(s) X 5234.00 S <br /> A <br /> i TANK RETROFIT REPAIR FEE + $78.00/hour (3 hours min./FACILITY) • S2*..00 minimum <br /> R <br /> PIPING REPAIR FEE _ !78.(10/hour (3 hours minim n/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE + !20.00 UNAUTHORIZED RELEASE EVALUATION = SM OO/hr S <br /> I t <br /> s _ <br /> C CONSULTATiON FEE _ $78.00/hr SAMPLING INSPECTION FEE _ 178.00/hr S <br /> TOTAL DUE $ �,00 <br /> FCA OFFICE USE ONLY <br /> mmism <br /> i t o SII N !I mIttliltlWGtl11 i ti I n n i!n! uti`c�au!ronn'rI!: :;; �::..!:rnr.;�.;,,.,.;i <br /> SWEEPS 0 COMPUTER 0 LOC CODE DIST CODE AMOUNT RECEIVED CHECK WASH RECEIVED 8Y DATE RECEIVEO <br /> taotnuerm i <br /> x+ !r,�n!ncnrrnt ,nF[ ,m;n!!: t?!pmt n�r:,m ;.;:,;�:�. s <br /> EH 23 032 (REVISED 1 12 98) <br />