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DERGROUND STORAGE TANK PROGRAM FEE WORKS <br /> F FACILITY/SITE NAME FACILITY CONT CT NAME <br /> A <br /> fy) <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> 1 19 say HT1 Y} IC ���i ��� ao - 939 - 73 a3 <br /> T <br /> Y CITYTATE IIP CODE t of TANKES 3 <br /> ��C(tlL O IJ 0A, 96 3Q0 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PS&m C,0 RlcH `11- D P) <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> A X131 WE PAT C1 D <br /> N CITY STATE TIP CODE ' TYPE of APPLICATION <br /> T TO 06-S� (�(� ()535 I (Closure, Installation, etc.) CLAS) F L <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply 1-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Set 25287 for applicability) <br /> I <br /> T t Tanks x (56.00 1986 1987 1988 1989 <br /> Y (enter a�iount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE = $90.00 each TANK 1 Tanks x $90.00 f p, O O <br /> S <br /> U <br /> R ncunc rn I ,11,I one time for up to two years) <br /> E <br /> SEMICO <br /> TERRY HAMILTON, PRESIDENT ,�...- <br /> RICHARD C. HAMILTON V P 1451 <br /> IALAL <br /> PH. 209-5249653431 W. HATCH ROAD <br /> PAYMODESTO, CA 95351 ---19--/— 90-1314/1211 <br /> ORDEERR OF <br /> N 1 <br /> - <br /> $ o)-70 00 <br /> UNION SAFE °° r L ^_R s T' f <br /> DEPOSIT <br /> 4"e,oxa.ar,sera BANK, U 11 <br /> 1 <br /> MEMO <br /> $ Z7o GV <br /> r <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP f LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1 CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 40FO D6 32(,:;, P�zZ' Ai 70` /C/S C•U /A07 <br />