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SAN JOAQUIN COUNT•UBLIC HEALTH SERVICES-ENVIRONSIEN L HEALTH DIVISION000188 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Lawrence Livermore National Laboraw •(LLNL) (.. Susi Jackson <br /> T FACILITY ADDRESS SITE PHONE#with AREA CODE 1J <br /> E Corral Hollow Road (5 lo) -423-4891 #OF TANKS at SITE <br /> & CITY STATE ZIPc'ODE <br /> A c„uthwest,�f Tracy CA 94550 4 for Building 879 <br /> P APPLICANT/139-LINGNA,�tE APPI.ic:ANTCONTA(TNAME <br /> P LL'vL ('. tiu.i Jack,on <br /> L MAI1 INC ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I 70(x( Ea.t Ave.. P.O. Box x(tx, <br /> 01(J} 423-6577 <br /> C CITYSTATE ZIP COOE TYPE OF APPLICATION(Closure.Installation.eta.) <br /> ;N Livermore CA y4i;u Tank cl,,.urc <br /> TI TI)T 4L <br /> F(if <br /> .L FACILITY FEE(Pn,,r t,, l)xr, )olx7 l`�xx 19x9 :•)vo <br /> 1. 1`)91) =S1lK(.00 S <br /> ITY PENALTY FEES ASSESSED xxxx xxxxlicable) <br /> FEE=S50.00/TANK(Pnor n,January L 1991) 1701 TANK <br /> Atter Janua 1. 1991) <br /> = 911, 19x7 19111 1919 l�wo 1991 199: 1993 199.4 1995 1996 <br /> ly # by fee for S <br /> year applicable <br /> I S <br /> L TANK PENALTY xxx xxx <br /> I FEES ASSESSED <br /> T STATE SURCHARGE=551,each TANK(Due every 5 years)See California H&S Cale.Sa uun 25287 <br /> Y <br /> #Tanks =_x 551,.()()(enter am,+uut and year) 19x1, thnoueh 1990 . 1991 through 1996 S <br /> C EIIANENLOSURE(Removal or Authorized Closure-in-Place) TANK I.D.#(s) cd <br /> L ETTN!/ 7// <br /> O -5790)/hour(3 hours mmtmumfIANK) TANK I.D.#(s)�_x 5234.00= S 234. 7 <br /> S <br /> tr LOSURE(Plan Review&inspections) TANK I.D. <br /> LOSURE FEE=S7x.Wft1ur #TANK(s)_x 5234.00= S <br /> m/IANK) <br /> P INSTALLATION PLAN CHECK(Plan Review&Construction TANK I.D. #ls) <br /> L Inspections) 5 <br /> A PLAN CHECK FEE-S78.00Arour(8 hours minimurst/Facilityl=S624.00 minimum <br /> N <br /> R FREPAIRFEE(Workplan Review &Construction Inspectium) TANK I.D. #(s) <br /> EP NING REPAIR FEE=S78.00/hour(3 hours TANK I.D.#(s) x S <br /> A /TANK) 5234.00 <br /> I TROFIT'REPAIR FEE=S78/hour(3 hours mi <br /> mmum/FACILITY)=S2_�i minimum S <br /> R <br /> PIPING REPAIR FEE=S79.00/hour(3 lruur mi:-:mum/FACILITY)=S234.00 minimum S <br /> M TRANSFER FEE=S20.00 CRvAI FRK�RIZED RELEASE EVALUATION= S <br /> I 578.00/hr <br /> S CONSULTATION FEE=S714.00/hr SAMPLING INSPECTION FEE=S78.00/hr 5 <br /> w <br /> C <br /> TOTAL <br /> DUE <br /> 5 23 <br /> 4. <br /> OFFICIAL L SE ONL _ ::. ,.. .. ....... .,...... . <br /> SWEEPS# COMPLRER# LOC DIST At`xx tNT CHECK#/ RECEIVED DATE RECEIVED <br /> ('ODE C( RC'vl) CASH BY <br /> EH 2j'032(Revised 11-1'-92) <br /> ll <br />