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0 <br /> 6 <br /> r( 1^64 t.A I t AUNIK$?�, <br /> � n SITE PHONE x With AREA CODE <br /> L } y --R 2"-7 , - 3 75S <br /> A <br /> CITY STATE ZIP CODE t of TANKS <br /> _ 1 <br /> P q5290 at SITE <br /> P1 APPLICANT/BILLING NAW. APPLICANT CONTACT NAME <br /> L 'EC\ri ., <br /> IL W(fit 1 <br /> MAILING ADDRESS APPLICANT PNOxE S WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> S('m Sc;SSG �.rsT��..r��� <br /> GS►)a, (Closure, Ynststtatton, etc.) <br /> r- <br /> TOTAL <br /> ANNUAL FACILITY FRE (Price to January 1, 1941) s 2100.00 1986 1987 11988 19$9 1 1990 <br /> Cx= I =cxx= ==-Txxxx s <br /> T FACILITY PENALTY FEES ASSESSED (If Appticabte) X)00( ' X)QOf XXXX XXXX XXXx S <br /> I <br /> Y} TANK FEE = S50.OD/TANK CPrior to January 1,1941) s170/TANK (After January 1, 1991) <br /> E <br /> Y Tanks y a by fee for 1487 7988 <br /> F (Wait-igty 1984 1990 11941 1992 TM 7994 1995 1996 1997 <br /> I <br /> A qhs year aW icabie) XXXX f xxxx =cx wx =ix + 1 I f <br /> C i(( <br /> 11 TANK PENALTY FEES ASSESSED =cx )0= XXXX XX)OC Xx70I I i I S <br /> I STATE SURLNARGE FOR NEW FACILITIES ONLY a 518.50 {2 <br /> T <br /> Y x Tanks x 58.00 19ft through 1990 (SS6D 1991 through 7446 CS56) 1997 <br /> SURCHARGE FOR 1997 S <br /> C1 PERMANENT CLOSURE (Removat or Authorized Closure-in-Ptate) TANK I.D. 0(s) <br /> L <br /> 0 <br /> S CLOMME FEE . 578-00/hour (3 hours mini=av/TANK) S TAAX(s) X s234.00 = S <br /> U TEMPORARY CLOSURE Men Review L Inspections) I TANK I.D. t(S) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours miniauWFACILITY) ! 523 .00 m9niama. S <br /> P INSTALLATION PLAN CKCK (Flan Review i Coratruerion 1"awtions) T <br /> L AMC L.D. S(s) <br /> AlNPLAN CNECK FEE n $78.OQ/hcw CS hours a ainimWPACILITY) ■ S624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK S.D. Ks) <br /> E <br /> P TANK LINING REPAIR FEE z 578.00/hour C3 hours miniAWTARK) 0 TANK(s) X SM-00 : S <br /> A <br /> I TANK RETROFIT REPAIR FEE r VM.00/hour (3 hours min./FACILITY) a S4_0Q minifto S <br /> R <br /> PIPING REPAIR FEE s 278.0o/hour (3 Hours a tjnimWFACILITY) s23G.00 aa;Riaes s <br /> N TRANSFER FEE S 220.00 � UNAUZW RELEASE EVALUATION = S78.00/hr <br /> I TNQRI +'s StTm s��•C� <br /> s , <br /> C CONSULTATION FEE : 278.00/hr SAMPLING INSPECTIOII FY{E s SM.04/hr { S <br /> TOTAL DUE f <br /> FOR OFFICE USE any <br /> S1rEEP5 x ................_. <br /> COMPUTER 8 LOC CGDE I DIST CODE AMOtAtT RECEIVED <br /> • <br /> 1 I f CHECK #/CASH RLCEIVED 3Y DATE RgCEIVEO -� <br /> 4 <br />