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� .- 1rri. � Arlr•�� <br /> -ITY/SITE HARE FACILITY CONTAC' , <br /> F-K � � Y- ��� STEve 6K <br /> STREET ADDRESS SITE PHONE I (with Area Code) <br /> r o2,L18' r, K TILE mA^1 I- 4n16, <br /> T <br /> CITY LDQl TE Ip FADE s of TANK'S <br /> �. ` Say/ at site <br /> ' P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> II MAILINVORESSn Q APPLICANT PHONE 1 (vith tea Code) <br /> A 0 (RDx ao - 33 - 099 <br /> T C(iY L O TATE II CODE TYPE of APPLICATION <br /> f} a tl f (Closure Installation, etc.) D'o"wez <br /> FACILITY FEE = $100 00 each SITE ADDRESS per YEAR TOTAL <br /> ' C 198b 1987 1988 1989 <br /> A <br /> T <br /> I S <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A (IrultipTy-l-by fee for <br /> ' 1 each year applicable) 1 <br /> 1 STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Set 25287 for applicability) f <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> ' Y (enter RKn—t and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> CLOSURE FEE = $90 00 each TANK I Tanks— x 190.00 $ Q .p O <br /> 5 <br /> 11 <br /> SEMCO 1512 <br /> TERRY HAMILTON PRESIDENT S I <br /> RICHARD C HAMILTON V P / �j QQ <br /> ' PH 209-524-9653 — /I' / 4 / <br /> 431 W HATCH ROAD l9 8Q-i314/til <br /> MODESTO CA 95351 <br /> AY TO THE <br /> DER OF <br /> D <br /> ��✓ C7t rDOLLARS <br /> UNION SAFE <br /> DEPOSIT <br /> DANK I <br /> +moo a.ow By s.lwa CA 05m <br /> ttal) <br /> i 21113 1413a: i5 1281, 031,10674411011' <br /> rm= z+sv.vvrnr FEE : $35.100111Ir FEE = $35.00/hT ; <br /> TOTAL DUE s 'I <br /> OFFICE USE O!I[Y I <br /> I <br /> I <br /> SWEEPS i COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD� CHECK I/CASH RCVD 8Y DATE RECEIVED PERMIT I <br /> 3y� Way , 39a, ego <br />