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SAN QUIN COUNTY ENVIRONMENTAL HEALTH DLOTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME LLNL — Site 300 Shari Bri don FACILITY ADDRESS SITE PHONE# WITH AREA CODE rprral Hallaw Rd- (92-5-1423-7665 CITY STATE ZIP CODE I # OF TANKS AT SITE Tracy CA 95376 5 APPLICANT BILLING NAME APPLICANT CONTACT NAME Lawrence Livermove National Laboratory Shari Brigdon APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE EO Box 808, L-627 925 423-7665 CITY STATE ZIP CODE ($170) X (#tanks) CIRCLE WORK TO BE DONE: Closure Installation(:ED Retrofit Livermore CA 94551 Lj ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1998 1999 2000 2001 2002 2003 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) ($170) X (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR WA SAMPLING INSPECTION FEE _ $ 93/ HOUR $125 PER TANK AFTER FIRST TANK $N A $ N/A TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ N/A PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY $ N/A $ N/A REPAIR PLAN CHECK TANKID# s : 390002319450505184 879—G3U1 replace mechanical line leak detec or TANK RETROFIT REPAIR FEE = $279r/ FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. $ 279.0 PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. A MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE = $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR WA SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED CHECK I RECEIVED BY DATE RECEIVED SR I I I j EH 23 032 (REVISED 11124103)