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S <br />I <br />T <br />E <br />& <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />I <br />L <br />I <br />T <br />Y <br />( <br />L <br />( <br />L <br />A <br />E <br />F <br />L <br />A <br />N <br />R <br />E <br />P <br />A <br />I <br />SAN jGAQtjjN IL PUBLIC HEALTH SERVICES - ENVIRONN8ffAL &H DIVSIGN <br />UWERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY SITE NAME <br />FACILITY CONTACT <br />5 Lo Gu v T <br />f R v \ H <br />FACILITY ADDRESS <br />ITE P NE # with AREA CODE <br />7U- 3o�4 <br />CITY <br />STATEI <br />ZIP CODE I # of TANKS <br />at SITE <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />—7 L \7 s c <br />= � <br />MAILING ADDRESS <br />- ' <br />APPLICANT PHONE # WITH AREA CODE <br />��\& CQ3 5- z 444 Ex -7-7 <br />2 LA L zv <br />1993 11994 1995 1996 11997 <br />CITY <br />STATE ZIP CODE TY )PLICATION <br />I C C .� <br />2 Closure, Installation, etc.) <br />TOTAL <br />A <br />C <br />T <br />V <br />E <br />F <br />A <br />C <br />1986 11987 11988 <br />1989 11990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />XXXX ( XXXX I <br />XXXX XXXX S XXXXXXXX <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX I XXXX XXXX ( <br />XXXX XXXX S XXXXXXXX <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January <br />1, 1991) <br />A Tanks = 1989 1990 11991 11992 <br />1993 11994 1995 1996 11997 <br />1998 <br />(multiply # by fee for <br />HanXXXX I XXXX I XXXX XXXX I <br />I I ( <br />I S <br />each year applicable) <br />TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I XXXX (XXXX I <br />I ! <br />I S <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />S <br />Tanks x 58.00 1988 through 1993 ($56) <br />1993 through 1997 (556) 1998 <br />SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXX X <br />S <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />TANK I.D. #(s) <br />CLOSURE FEE= 578.00/hour (3 hours minimum/TANK)I <br /># TANK(s) Z— X 3234.00 <br />= S <br />TEMPORARY CLOSURE (Plan Review & Inspections) I <br />TANK I.D. #(s) <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I <br />$234.00 minimum <br />S <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />PLAN CHECK FEE = 578.00/hour (8 hours minimus/FACILITY) <br />= S624.00 minimumS <br />REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.D. #(s) <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK)I <br /># TANK(s) X $234.00 = S <br />m <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 has min./FACILITY) <br />- 5234.00 minimum <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5734.00 minimum $ <br />H TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br />S <br />C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I I S <br />TOTAL DUE s Qg vJ <br />co ns:FTrF msao: nns Y <br />EH 23 032 (REVISED 1-12-98) <br />