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r U GRam Stomal TANK PROMM - FEE UCRKJ" <br /> FACILITY SITE NAI! FACILI,. a*TACT MW .` <br /> A fC CLLE� I IeGcC kb G�fu��� f�E�� <br /> C site PHONE 0 with AREA =1 <br /> I FACILITY AD DRESS �0L t� <br /> I STATE 21Ft CODEof TANK! <br /> T CITY ��t��o� � 5Z/� st !ITE <br /> A APPLICANT/9ILLINO NMI APPLICANT CONTACT NAME <br /> P <br /> ! RAILING ADDRESS APPLICANT PHONE 0 tir TN AREA CODE <br /> C c{3/ l� /` r1T I�6A 24 z Q`6 53 <br /> CIYr 0� 7� f �E x1 1 TYPE of APPLICATION <br /> T `77 CLOSURE, INSTALLATION, +Ite. <br /> TOTAL <br /> A <br /> C 1966 1947 1966 1969 1990 <br /> Y ANNUAL FACILITY FEE (Prior to Jw%wry 1. 1991) a $100.00 <br /> E � <br /> Y . <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) $170/TANK (atter January 1, 1991) <br /> F f Tanks 1966 1967 1968 1969 1999 1991 1992 1993 1994 199'5 1996 <br /> A (muttlpty W-67-fes for <br /> C tech year spplleebte) S <br /> I <br /> L STATE SURCHARGE ■ $56,00 each TANK (Due every S years) fro Cattfornla H 3 S Code, Section 25257 <br /> I <br /> T ! Tarns x $56.00 1966 through 1990 1991 through 1996 <br /> Y (ante' aloouit find year) <br /> 3 <br /> PERKANENT CLOSURE (Rearnal or Authorlted Closur*-In-Ptace) TANK 1.0. 6(a) <br /> C <br /> L CLOSURE TEE 153.00 per hour (3 hours ainlisW TAIIK) R TANK(s) 1 X $159.00 <br /> MODr.STO BANKING COMPANY 90-3732/1211 <br /> xaa. wf CW*Nn♦ ♦VZNV■ <br /> rwao■sTo,CAuPoRMA 91*$0 <br /> SEEMCO 5469 3 <br /> GF.NERAt- 1 NGINEFRMNG & BNViNONMENTAL CONTRAC'E'OR - <br /> 431 VY. HATCH RD, (209) 524-9653 <br /> MODESTO,CALIFORNIA 95351 <br /> 3 <br /> %Y SEMt N.k DOLS CTS DOLLARS <br /> TO THE ORDER OF DATF; CHECK NO. AMOUNT <br /> S EMCO 3 <br /> 71Q0 <br /> YM■wAll�tA••••'w••��"'gw:niiwi::w:ir3wi`.,'ir ww w+w►�w w.:arw.w"�ww.r r��w��wa e:►�i.:w�T"'�n:esw iww is iFwii►iN:wi�:eiwwrw i+�w 1�■iw■w i:.waw�+.� <br /> 1 7wt tYY>�t RR if 11f.-W ��� �A�A �MRATE-REU I'MOVIIMM1� <br /> ■..a»w.w rw M..•r s..�— <br /> ■ MMM Mlma velr 1■M AW 4wss wMwNw q1am m mawows wOry o.y�■w wows ii,s>es.w iww'�ww iii iiiw w.e w.w owe w iii w:oa nus1�ww ii.►wiiw�>ww wM+oe"w.�i:.i, <br /> Ar��laaM aR�/�Ia1K aRA[MaM 111!Aa1��Jlli Ai AaM ap a1IKAi J14111'!M Ave''alio i rwr r= <br /> EN 23 02 (REV 4"/91) ft <br />