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SA% JOAQUIN COLN'TY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION 000284 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACIIITY SITE NAME FACUM CONTACT NAME <br /> I Lawrence Livermore National Labor LLNL C. Susi Jackson_ <br /> T FACILITY ADDRESS SITE PHONE#with AREA CODE <br /> E Corral Hollow Road 510 423-4881 <br /> & CITY STATE Z1P CODE #OF TANKS at SI'T'E <br /> A T CA 94550 2 for Building 827 <br /> P APPLICANT/BILlING NAME APPLICANT CONTACT NAME <br /> P LLNL C. Susi Jackson <br /> L MAII LNG ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I 7000 East Ave- P.O.Box 808 510 423-6577 <br /> C CITY STATE ZIPCODE TYPE OF APPLICATION(Closure.Installation,etc.) <br /> A <br /> N Livermore CA 94550 Tank closure <br /> T <br /> TOTAL <br /> A ANNUAL,FACILITY FEE(Prior to 1986 1987 1988 1989 1990 <br /> C January 1, 1991) =S100.00 <br /> T S <br /> I <br /> V FACILITY PENALTY FEES ASSESSED xxxx xxxx $ <br /> E if a licable <br /> TANK FEE=S50.00/TANK(Prior to January 1, 1991) 170/TANK <br /> After Janu 1, 1991 <br /> F #Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply #by fee for <br /> C each year applicable S <br /> I <br /> L TANK PENALTY xxx xxx S <br /> I FEES ASSESSED <br /> T STATE SURCHARGE=S56 each TANK(Due every 5 years)See California H&S Code,Section 25287 <br /> Y <br /> #Tanks= x S56.00(enter amount and, 1986 throw h 1990 1991 through 1996 <br /> S <br /> C PERMANENT CLOSURE(Removal or Authorized Closure-in-Place) TANK I.D.#(s) <br /> L <br /> O CLOSURE FEE-S78.00/hour(3 hours minimum/TANK) TANK I.D.#(s)� I x$234.00= S 234,00 <br /> S <br /> U TEMPORARY CLOSURE(Plan Review&Inspections) TANK I.D. <br /> R # s <br /> E TEMPORARY CLOSURE FEE=S78.00/hour #TANK(s)®x 5234.00= Is <br /> hours minimu n-u TANK <br /> P INSTALLATION PLAN CHECK(Plan Review&Construction TANK I.D. #(s) <br /> L Ins ctions <br /> A PLAN CHECK FEE-S78.00/hour(8 hours minimum/Facility)=$624.00 minimum S <br /> N <br /> R REPAIR FEE(Workplan Review&Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE=S78.00fiour(3 hours TANK I.D.#(s) x S <br /> A minimum/TANK) 5234.00 = <br /> I TANK RETROFIT REPAIR FEE=S78/hour(3 hours minimum/FACHXM=S234 minimum S <br /> R <br /> PIPING REPAIR FEE=S78.00/hoir hour nummum/FACI =S234.00 minimum $ <br /> M TRANSFER FEE=S20.00 UNAUTHORDW RELEASE EVALUATION= S <br /> I I S78.00/hr <br /> S CONSULTATION FEE=$78.00/hr SAMPLING INSPECTION FEE=S78.00/hr S <br /> C <br /> OFFICIAL USE ONLY TOTAL DUEIS 234i <br /> SWEEPS#,.... COMPUTER# IAC DIST AMOUNT CHEC # RECEIVED DATEREC'FIVID <br /> CODE CODE RCVD CASH BY C <br /> S <br /> •.`,.::2::;:G::>.::::w::::t:�2:•..,:..:::::::iJ2:2:iAtiW'.��:::.:A:::::v::\".::A`.:::::::a::i2:2:2"w':an3'iiAJ�a :�^22v.::•.�:::i:oiw:2.3:•.. a.cak2�3,w,ta.,.aY.te.cW.dw.`u..,aw`a.-.+R.,,....,,t <br /> EH 23 032(Revised 11-1-92) <br /> 11 <br />