Hazardous Waste Facility Permit Fee Transmittal {47214}

HAZARDOUS WASTE FACILITY PERMIT FEE TRANSMITTAL State Form 47214 (R7 / 5-14) Approved by State Board of Accounts, 2014 Indiana Department of Environmental Management INSTRUCTIONS: This form must be used to transmit fees for all hazardous waste management facility permits, applications and modifications (NEW permits, RENEWAL of permits, Class 2 & 3 MODIFICATION of permits) pursuant to IC 13-16, and is to accompany all payments. Make check or money order payable to the Indiana Department of Environmental Management. For payment by Master Card or Visa please visit the IDEM Cashier's office or contact the office by telephone at 317-232-8705 Monday through Friday between the hours of 9:00am to 3:00pm. Your check, money order or IDEM issued credit card receipt and this fee transmittal form must be attached to your permit application. Submit application or modification materials to: Indiana Department of Environmental Management Office of Land Quality Chief, Hazardous Waste Permits Section 100 North Senate Avenue, Room 1101 Indianapolis, IN 46204-2251 Section A. Applicant(s) Information Name Mailing Address: State Facility Name and County Street ZIP Code Apartment Number P.O. Box Town/City Telephone Number (with area code) Section B. Hazardous Waste Permit Fee Schedule The following fees are to accompany permit applications and modifications. A person or facility that is described in more than one category must pay all applicable fees in accordance with 329 IAC 3.1-1-14.1(b). Class 3 Class 2 New Permit Type of Facility Permit Renewal Modification Modification Application Hazardous Waste Landfill Hazardous Waste Incinerator Hazardous Waste Storage Facility Hazardous Waste Treatment Facility $40,600 $21,700 (per Unit) $23,800 $23,800 $34,000 $21,700 (per Unit) $17,200 $17,200 $34,000 $21,700 (per Unit) $17,200 $17,200 $2,500 $2,500 $2,500 $2,500 Account # 2830-412300-100800 American LegalNet, Inc. www.FormsWorkFlow.com