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I911.11" �OMIACI NMIE <br /> 'M X LA-14 <br /> i STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> T S ' �G — n —Z/ 91? <br /> Y CITY STATE TIP LODE 1 0l TAN915 <br /> S`F'lx-dCT'D/�1 [q . 5.207 +t Site I <br /> A APPLICANT/BILLING NAME ---JAPPLICANT CONTACT NAME <br /> P <br /> P <br /> L t4 xAA E L'TOnF <br /> C MAILING ADDRESS APPLICANT PHONE B (with Area Code) <br /> A � �< - 3 - `I 61 IS- <br /> H CITY STATE TIP CODE T PLICATION <br /> T Mr/P�✓t�� « ' S�tSl losure Installation, etc.) <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> SENICO 1497 <br /> TERRY HAMILTON, PRESIDENT <br /> RICHARD C. HAMILTON, V.P. <br /> PH. 209-524-9653 9-- �- r� <br /> 431 W. HATCH ROAD - 19_ { <br /> MODESTO, CA 95351 <br /> PAY TO THE J $ t'O, 20 <br /> ORDER OF '� - -- ----- - / <br /> ((UNION SAFE 1 <br /> DEPOSIT <br /> DANKAr� �I� <br /> b ur Wway.Se' Cn <br /> O V' V(�1\ <br /> - <br /> r <br /> rLL swo.00 each TANK 1 Tanks.---- a {80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE 030.00 each SUBMISSION/RESUBMISSION <br /> ----------------- 0 <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE • 1110.00 each TANK 1 Tanks : (110.00 { <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einieue one hour to he paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION <br /> INSPECTION <br /> FEE = 170.00/hr FEE L 135,00/hr FEE • tD5.00/hr { <br /> f <br /> OFFTCF USF ON(Y TOTAL DUE <br /> WSW <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DINE AMOUNT RCVD CN UCASH RCVD BY DATE RECEIVED PERMIT 1 <br /> o/ ��2 l/d�lrr <br />