HAZARDOUS WASTE FACILITY PERMIT FEE TRANSMITTAL State Form 47214 (R5 / 1-06) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Approved by State Board of Accounts, 2006 INSTRUCTIONS: This form shall be used to transmit fees for all hazardous waste facility permits, applications, and modifications (NEW permits, RENEWALS of permits, Class 2 & 3 MODIFICATIONS of permits) pursuant to legislation IC 13-16, and is to accompany all payments. Make check or money order payable to the Indiana Department of Environmental Management. Upon completion, return this form and appropriate fees to the following address: Glynda Oakes (N1154) Indiana Department of Environmental Management Office of Land Quality Permits – Mail Code 66-20 100 North Senate Avenue Indianapolis, IN 46204-2251 A COPY of your check and a COPY of this fee transmittal form must be attached to your permit application. Submit application and modification materials to: Mr. Victor P. Windle Indiana Department of Environmental Management Office of Land Quality Permits – Mail Code 66-20 100 North Senate Avenue Indianapolis, IN 46204-2251 SECTION A. APPLICANT(S) INFORMATION NAME: MAILING ADDRESS: Street State City ZIP TELEPHONE NUMBER: FACILITY NAME and COUNTY: APPLICATION TYPE FEE AMOUNT ACC. #2830-412300-100800 American LegalNet, Inc. www.FormsWorkflow.com SECTION B. HAZARDOUS WASTE PERMIT FEE SCHEDULE The following fees are to accompany applications and modifications. A person or facility that is described in more than one (1) category must pay all applicable fees 329 IAC 3.1-1-14.1(b). Please circle the fee(s) which you are paying. Type of Facility New Permit Application Permit Renewal Class 3 Modification Class 2 Modification Hazardous Waste Landfill $40,600 $34,000 $34,000 $2,250 Hazardous Waste Incinerator $21,700 (per unit) $21,700 (per unit) $21,700 (per unit) $2,250 Hazardous Waste Storage Facility $23,800 $17,200 $17,200 $2,250 Hazardous Waste Treatment Facility $23,800 $17,200 $17,200 $2,250 Part B for Existing Storage Facility* $23,800 N/A N/A N/A Part B for Existing Treatment Facility* $23,800 N/A N/A N/A *Applies to interim status facility seeking first permit American LegalNet, Inc. www.FormsWorkflow.com