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IFI FACILITY/SITE NAME (FACILITY CONTACT NAME <br /> d'C 0t'f 1'/0 k 006)b S A,2T KoK o rJ <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA COOS <br /> [ �0 �./Atjn�L'f� FtEll�ljTS KD d0� �f - I 7 s <br /> T --� --- — <br /> Y UIS Ji STATE ZIP CODE 1 of Tanks <br /> C -- <br /> at Site —j \A/0 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> W0Llt1J � S0/\JS j/QL A& T Kv�v�J <br /> L - —— --- <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> A P. O. god( 18 — a0 X6 .7 1 <br /> N CITY STATE iIP CODE TYPE of APPLICATION <br /> T_ S U T ri L t Y CLOSURE. INSTALLATION, ETC. y / M ov6 L <br /> TOTAL <br /> C WOLIN & SONS ao9 237 <br /> -- <br /> T H. A. ANDERSON <br /> P.O. BOX 98 p �/ <br /> IV_ SUTTER CREEK, CA 95685 "-�0 199 <br /> / 9D-7097/3211 -- <br /> F <br /> ORDER OFEc� D 0 L <br /> u/fes? 0e-"l <br /> AI DOLLARS <br /> °"= EL=DORADO SAY( - <br /> T .P.O.Boa 277,52 Main St. <br /> Y Sutter Creek.California 95685 <br /> MEMO <br /> LJ- <br /> C <br /> C <br /> L <br /> 0 CLOSURE FEE = S'30.00 each TANK I 1 Tanks_-x $30.00 I S c'v 2C' <br /> U <br /> R TEMPOP.ARY CLOSURE (Only al%Owed one time for up to two years) <br /> TEMFOP.AF.Y CLOSURE FEE - ('k- ach TANK Tanks — x E90.OI) $ <br /> ---.._......... --- ------ <br /> PIPLAN CHECK ( llatta�r P.epa11� T <br /> III FLAN CHECK FEE �Nyneach SUBMISSION/RESUDMISSION <br /> --.. <br /> F. TANK REPAIR FEE = $110.00 each TAITK �t Tanks x $110.00 f <br /> A PIPING REPAIR./CLOSUF.E/P.EMOVAL (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 _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ ° <br /> OFFICE USE ONLY <br /> M PL U91rM, �'u001 92 M 1191RGB@ M �, d <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> f 5 u0r✓tP Q CSI I g�= jti00 <br /> zt�•;.,°�_'.;�}}: ,;� :�:'--.;-.- r •,.:.z.;,_..,<._,.-,.--•, T i� - ■ � i ��� � lei - - - - a ■� <br />