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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE S-ENVIRONNIE AL HEALTH DIVISION 4 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACIL11Y SITE NAME FACILITY CONTACT NAME <br /> I Lawrence Livermore Natio+nal Laboratory(LLNL) C. Susi Jackson <br /> T FACILITY ADDRESSSITE PHONE#with AREA CODE <br /> E Corral Hollow Road (510) 423-4881 <br /> & C1TY STATE ZIP CODE #OF TANKS at SITE <br /> A (southwest of)Tracv I CA L 94550 1 for Building 805 <br /> P APPLICANT/BILLING NAME APPLICANTCONTACT NAME <br /> P LIINL C. Susi Jackson <br /> L MATTING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I 70(1)) East Ave.. P.O. Box 808. (510) 423-6577 <br /> C CITY STATE ZIP CODE 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 1996— <br /> C January 1. 1991) =S100.00 <br /> T <br /> I <br /> V FACILITY PENALTY FEES ASSESSED xxxx xxxx $ <br /> E (if a Iicable) <br /> TANK FEE=S-50.00/TANK(Prior tit January 1. 1991) 170/TANK <br /> After Janu• 1. 1991) <br /> F #Tanks = 1986 1987 192)8 19tt9 1990 1991 1992 1993 1994 1 1995 1996 <br /> A (multiply #by fee for $ <br /> C each year applicable <br /> I <br /> L TANK PENALTY xxx xxx $ <br /> I FEES ASSESSED <br /> T STATE SURCHARGE=556 e u h TANK(Due every 5 yeah)Sea California H&S Cowie.Section 25287 <br /> Y <br /> #Tanks =e x 556.00(enter amount and year) 1986 through 1990 1991 through 1996 <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 minimumflANK) TANK I.D.#(s) 1 x 5234.00= S 234 <br /> S <br /> U TEMPORARY CLOSURE(Plan Review&Inspections) TANK I.D. <br /> R I#(s) <br /> E TEMPORARY CLOSURE FEE=S78.00/hour #TANK(s)_x 5234.00= $ <br /> (3 hours mintmumlrANK) <br /> P INSTALLATION PLAN CHECK(Plan Review&Construction TANK I.D. #(s) <br /> L Insactions) <br /> A PLAN CHECK FEE-S78.00/hour(8 hours minimum/Facility)=S624.00 minimum S <br /> N <br /> R REPAIR FEE(Workplan Review&Construction Inspections) TANK LD. #(s) <br /> E <br /> P TANK LINING REPAIR FEE=S78.00/hour(3 1x-lurs TANK I.D.#(s) x 5 <br /> A minimurr'I4NK) 5234.00 = <br /> I TANK RETROFIT REPAIR FEE=S7 /hour(3 hours minrmum/FACILITI')=S234 nununum S <br /> R <br /> PIPING REPAIR FEE=S78.00/hour(3 hour minimum/FACILIIY)=S234.00 minimum S <br /> M TRANSFER FEE=S20.00 ±S78.001hr <br /> At t l tit. MED RELEASE EVALUATION= S <br /> I <br /> S CONSIJLTATION FEE=S78.Ut1/lyl•SpLING INSPECTION ET E=S78.00Vhr S <br /> OFFICIAL USE ONLY TOTAL DUE 5 234 <br /> :?n\•+'A!'?.Y!..4i`i. ,�v.,\J.\1\h\\'i\^:O*•i\hJ,:;?:XJW ^''xY•t'•:f:. <br /> :v.. :::::::::::x::�•:::e:::::. �{.v+p•:.,.,.. ♦.., Wil+? <br /> ...,..:.:..:"...:.:.,'n...:.............::.:.v.:..:•...ti.;::::is iiiYii;Ni:;{:•:::....... ....... .._. ........ .�:...::.... <br /> RECEIVED ATE <br /> SWEEPS# CObiPt t 1 ER# LOC DIST AMOUIcfI CHECK#/ DRECEIVED <br /> CODE CODE RCVD CASH BY <br /> ::.::::::::::.::::::.:...::::::::::.�::{�:?•:;:?••,::::;,:;::::RJa;S:>nrn:r::.coxa'?R•::Q;{a\\;;,,,',.,a\„xaaaai:;<::t�::::a:SVRcr:.;r::., <br /> EH 23 032(Revised I 1-1-92) <br />