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SAN JOAQUIN COUNTY P C HEALTH SERVICES-ENVIRONMENT EALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Lawrence Livermore National Laboratory LLNL) C. Susi Jackson <br /> T FACHM ADDRESS SITE PHONE#with AREA CODE <br /> E Corral Hollow Road 510 423-6577 <br /> & CITY STATE I ZIP CODE #OF TANKS at SITE <br /> A Tracy CA 95376 1 for Building 830 <br /> P APPLICANTBILL NG NAME APPLICANT CONTACT NAME <br /> P I I Nl. C. Susi Jackson <br /> L MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I 7000 East Ave., P.O. Box 8081 (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 /> A ANNUAL FACILITY FEE(Prior to 1986 1987 1988 1989 1990 <br /> C January 1, 1991) = $100.00 <br /> T $ <br /> I <br /> V FACILITY PENALTY FEES ASSESSED xxxx xxxx $ <br /> E if applicable) <br /> TANK FEE=$50.00/TANK(Prior to January 1, 1991) $1.70/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 <br /> for <br /> C each year applicable $ <br /> I <br /> L TANK PENALTY xxx xxx $ <br /> I FEES ASSESSED <br /> T STATE SURCHARGE=$56 each TANK(Due every 5 years)See California H&S Code,Section 25287 <br /> Y <br /> #Tanks=®x$56.00(enter amount and year) 1 1986 throw h 1990 1991 through 1996 <br /> C PERMANENT CLOSURE(Removal or Authorized Closure-in-Place) TANK I.D.#(s) <br /> L <br /> O CLOSURE FEE-$78.00/hour(3 hours minimum/TANK) TANK I.D. #(s) 1 x $234.00= IS 234.00 <br /> S <br /> U TEMPORARY CLOSURE(Plan Review&Inspections) TANK I.D. <br /> R I #(s)------------------------ <br /> E TEMPORARY CLOSURE FEE=$78.00/hour #TANK(s)_x$234.00= $ <br /> (3 hours minimum/TANK) <br /> P INSTALLATION PLAN CHECK(Plan Review&Construction TANK I.D. #(s) <br /> L Ins ections <br /> A PLAN CHECK FEE-$78.00/hour(8 hours minimum/Facility)=$624.00 minimum $ <br /> N <br /> R REPAIR FEE(Workplan Review&Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE=$78.00/hour(3 hours TANK I.D.#(s) z $ <br /> A minimumfFANK) $234.00 = <br /> I TANK RETROFIT REPAIR FEE=$78/hour(3 hours minimum/FACILITY)=$234 minimum $ <br /> R <br /> PIPING REPAIR FEE=$78.00/hour(3 hour minimum/FACILITY)=$234.00 minimum $ <br /> M TRANSFER FEE=$20.00 UNAUTHORIZED RELEASE EVALUATION= $ <br /> I $78.00/hr <br /> S CONSULTATION FEE_$78.00/hr SAMPLING INSPECTION FEE=$78.00/hr $ <br /> C <br /> OFFICIAL USE ONLY TOTAL DUE $ 234.00 <br /> ................... ................. <br /> SWEEPS# COMPUTER# LOC CODE DIST CODE I AMOUNT RCVDI CHECK#/CASH RECEIVED BY DATE RECEIVED <br /> is <br /> a.•.e�.+oawa.•:.:,,,.cu:rrswsr„ss.....,:.,.,:........:::.,..:::,:,::..::.::::.:..,::::.,,::::::..::::::.:.,.::::.,,,,:...:.:::::::,.:.,:,,:...:.::.,,..................:......,::::::.,.:..,....::...ra....,....,r,.�:�u::,., <br /> EH 23 032(Revised 11-1-92) <br /> 11 <br />