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F FACILITY/SITE NAME FACILITY JkT NAME <br /> A . <br /> I ' R G'TtC7 t�13-tkem AOL <br /> I STREET ADDRESS SITE PHONE 1 (vith Area Code) <br /> T 1 —3'7 <br /> Y CITY STA E ZIP CODE �toSik�NKrB <br /> STt5C�0'ti,f, . <br /> APPLICANTl61LLlNG NAlIE cy� L-;, APPLICANT CONTACT NAMEPD <br /> 1 f L <br /> �5 ? <br /> IL NAILING ADDRESS APPLICANT PHONE 1 With Area Code) <br /> N CITYS, E IIP CODE jj PLICATION <br /> T /C)Pej V <br /> 53 r( losur Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1489 1989 <br /> T <br /> v $ <br /> E TANK FEE = $50,00 each TANK <br /> F I Torics x 150.00 1486 1487 1988 1989 <br /> A (nulliPli-1-by fee for <br /> C each year applicable) t <br /> I <br /> � <br /> STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for appli(ability) <br /> T I Tanks x $56.00 1986 1987 1986 1989 <br /> Y (enter iinunt and year) <br /> 1 <br /> C PERMANENT Ci.4SURE (Resoral or Closure-iii-place) <br /> L <br /> a CLOSURE FEE _ $40.00 each TANK 1 Tanks„?a-- x 490,Q0 i p 4 <br /> S Z7_ <br /> 109 <br /> TtRRY HAMILTON, pkSSlbeNt <br /> RICHARD C: HAMILTON Y p <br /> 431 W HATCH AD. 209424-9853 <br /> MODESTO, CA �� � 19 /0 „90-3732/1211 <br /> 1 r. p. � <br /> PAY THS <br /> y <br /> R© F a $ <br /> *� DOLLARS 7 <br /> �'M4{ ilftYtr �IE <br /> BA HIKING, Box sw <br /> CCIMMENAYAMEN <br /> UPART,NtO0E8TCP,CAUPOiiNIA 95a6� ' - <br /> M£MC3� <br /> TOTAL W1 00 {? <br /> OFFICE USE oirlr <br /> SWEEPS 1 CORP I LOC CODE DISI CODE AMOUNT DUE MINT RCVS CHECK IICASH RCVD DY DATE RECEIVED PERMIT 1 <br /> J <br />