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[([FACILITY/SITE NAME • <br /> FACILITY CONTACT NAME <br /> O'(W("ok' WOUDS I AP-1 Ko2orJ <br /> I <br /> L STREET ADDRESS SITE PHONE t NIT" ARE. coRE <br /> T,—'�00 L1AUJL-1� 4ul6NTS F-N — a - 73 <br /> Y CITY ' (-4 STATE ZIP CODE 1 of Tanks --- <br /> (� 9 g e) at Site j w0 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L WULInJ SOUS jNC— A& T Kdf20/J <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA ca" <br /> A P. o. 8oX �8 —.— a0 26 -7 <br /> N CITY STAGE ZIP/CODE TYPE of APPLICATION r <br /> T S U T ( Y-�2- c kEE K /{ {S/ 8� CLOSURE. INSTALLATION, ETC. RLMOvt1L <br /> A - TOTAL <br /> C WOLIN & SONS a0`/ z6 7 `� /l l 237 <br /> — <br /> T H. A. ANDERSON <br /> P.O. BOX 98 '7 p `'v/ <br /> Iti_ __ - _ SUTTER CREEK CA 95885 -_ "'oL0 190 / 99-7097/3211 --_ <br /> E __ _ - __ <br /> F' PAYE ROF THE <br /> ORDS r (1UC[..�L1 <br /> c L� <br /> A _ <br /> ' DOLLARS <br /> L --- f. <br /> ELDORADO SAVIEf -__ <br /> T P.O.Boa 277.62 Main St. <br /> Y "`���¢¢¢•TT Sutter Creek.California NS6B5 <br /> MEMO <br /> C — — <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 1 Tanks-,�--x $90.00 <br /> U ...-- -------- — — — <br /> R TEMPORARY CLOSURE (Only a%Owed one time for up to two years) <br /> iEHPOP.AF.I' CLOSURE FEE _ 0j pach TANi; 1 Tanks x $90.00 $ <br /> ---T0JN —.------ -- <br /> PPLAN CHECK llaho�o�r Repaip <br /> L $ --`p --- - — --.. —------- — - — <br /> I)I PLAN CHECK FEEeach SU9MISSION/RESUBMISSION $ <br /> ----------- — --- <br /> [REPAIR <br /> R TANK REPAIR FEE = S110.00 each TAI ' 1 Tanks x 1110.00 $ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum One hour to be paid On plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr� - _ - FEE = S35_00/hr�--- - FEE = $35_00/hr ----— (-_ — <br /> TOTAL DUE <br /> OFFICE OSE ONLY <br /> 9!�l �l Iii �Og9�l ll� mlp�l I@(U MUNI 9AMS MNIIi= 9=007MM �@. MP��IV�IE: <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CCVD BY DATE P,ECEIVED PERMIT 1 <br /> �pB�I 60 <br /> MUMM S/ <br />