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ITY/SITE NAME <br /> FACILITY CONTAC ME <br /> LA <br /> RESS <br /> �. KL�iYIA/J /�n/� SITE PHONE t (with Area Code) <br /> 1 o� 09 - 33�1 -0987 <br /> O/ / 0iiP, STATE tySay/ atof TANKIS <br /> Site <br /> BILLING NAME (f'� APPLICANT CONTACT NAME <br /> wEK � . . S-r6v�DRESS APPLICANT PHONE 1 (with Area Code) <br /> O . �ox la l o � 33Vr7Q ( TATE II CO.2 TYPE of APPLICATION <br /> R 5 (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1986 1989 <br /> T <br /> I <br /> V $ <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks _ _ x $50.00 1986 1 1? 1988 1989 <br /> A (:ultipiy ( by fee for <br /> I each year applicable) $ <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks __ x II , K 1986 1981 1988 1989 <br /> Y (enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks az $90.00 $ <br /> 5 <br /> SEMCO <br /> TERRY HAMILTON, PRESIDENT _ 1 51 Z $ <br /> RICHARD C. HAMILTON, V.P. <br /> 431 W.HATCH O D � $9 <br /> AMODESTO, CA 95357 <br /> Y TO TME �� <br /> RDER OF— _eI__- O O. <br /> OV VN E �D0'D DOLLARS <br /> UNION SAFE <br /> pMk\ BANK <br /> DEPOSIT n $ <br /> tial l <br /> rcc = ssu.uwnr IEEE _ $35.00/hrl IFEE _ $35.00/hr l f <br /> I <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD� CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />