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CITY/SITE NAME .. . . .. <br /> FACILITY CONTAC' <br /> ij <br /> STREET ADDRESS SITE PHONE I (with Area Code) <br /> T , fr1A nl L,gnl� <br /> ltlM Y CITY a 0 c1 — ,33�I -0 9 8 7 <br /> L per/ SATE Z� CODE It of TANK'S <br /> Cf'�► `�So7y/ at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> I MAIIiN§.A,DDRESSry a I v APPLICANT PHONE 1 (with Area Cade) <br /> A (t✓ o . o209 - 33 - 0 g - <br /> TCITY L Q TATE II CODE TYPE of APPLICATION <br /> f3 (Closure, Installation, etc.) �Q <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I <br /> V $ <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50,00 1986 1981 1988 1989 <br /> A (aultiplp-1-by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25281 for applicability) <br /> I i <br /> T 1 Tanks x $56.00 1986 1981 1988 1989 <br /> Y (enter iiount and year) <br /> S <br /> C PERMANENT CLOSURE (Reaoval or Closure-in-place) �I <br /> IL <br /> O CLOSURE FEE = $90.00 each TANK i Tanks_g__ x $90.00 S O <br /> SEMCO - <br /> TERRY HAMILTON, PRESIDENT 1..51.Z <br /> RICHARD C. HAMILTON, V.P. $ j <br /> PH.209-524-9653 <br /> 431 W. HATCH ROAD 4r 19 U / 9Q-1314/121 <br /> MODESTO, CA 95351 <br /> AY TO THE <br />-,RDER OF <br /> "v; E DOLLARS <br /> KION SAFE <br /> DEPOSIT <br /> BANK <br /> 48W Broaa.ay,Salida,CA 95368 <br /> ttal) <br /> 12111311,8 is 1S 12- 03­067tit, 01111 <br /> rcc = >,sv.vv/nr FEE = f35.00/hr FEE = $35.00/hr�+ S � <br /> I <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> i <br /> zzjvjz <br /> COMP I LOC'CODE DIST CODE AMOUNT DUE LAMOUNT RCVDt� CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> i <br /> III <br /> W�'�4 - <br /> i <br />