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HomeMy WebLinkAboutSIEFKER TR 16 E2MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH a HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ,�J S — 2 0/ — 15 'Alfa= / HAA # r-' L'2 G, r` \ (' 1. GENERAL INFORMATION Complete legal description SiEF�Ei2 S I ZZ) TISE)/2 Location (site address or directions) 35 35 /fru /4,,- a f ffyi 6, Property owner (fhe-�%Z /L Day phone Mailing address - S Cq��act C Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 2- 3. 3. TYPE OF WATER SUPPLY: Individual well — Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. h. TYPE OF WASTEWATER DISPOSAL: Individual on-site — Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 7M25 (Rev. 1191) Front MOA 021 5. .3 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm eA r%nw_11Zj Phone Address ,QVy 11/�%riryrf7ie,v iS��✓ CagCi %'yL , �K 9 �i S77 Engineer's signature DHHS SIGNATURE v Approved for bedrooms, Disapproved. Conditional approval for Additional Comments By.. _I L auTln Date ���A�Vop a�oe°aee�°o �tnV� /t�; 'aa> r4O 1 O r OAf-9E-i.T 0 Kenneth M. DV1V oo C-711 s FE bedrooms, with the following stipulations: Date3'2 '9�% The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev. IM) Back MOA X21 RFCFIVF 11J o Municipality of Anchorage MAR 2 2 1999 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNK-1PNu1r U, 825 L Street, Room 502 • Anchorage, Alaska 99501 • (9MR,94!3E4744LRvJUS uivisioi\ Health Authority Approval Checklist Legal Description: S`/EFKE4 S/a -TP, /ln E I/2 Parcel I,D.: Q/S - 2 e/ 1$ A. WELL DATA Well type Aq✓a�4 If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) /V Date completed Total depth b 5 used to 65 Casing height (above ground) 3 / Sanitary seal (Y/N) Wires properly protected (Y/N) / FROM WELL -60& AT INSPECTION Date of test _ �� D Z - 7 4 3- 2-0 -( 1 Static water level Well production T g.p.m. v2. /S g.p.m. Q --Pr w ev t!/ d:. Me, -r ��o. f a6�� 1216 2��0 7 WATER SAMPLE RESULTS: Coliform 0 Nitrate o?• 7 S/ Other bacteria WE Date of sample: d 3//9 Zgq Collected by: B. SEPTIC/HOLDING TANK DATA Date installed —4L99-2.1-21- Tank size / Oo U Number of Compartments 2--_ Cleanouts (Y/N)-�—_ Foundation cleanout (Y/N) _ V Depression (Y/N) A/ High water alarm (Y/N)!�/ /f" Date of Pumping t93LI7111 Pumper ZSSa6S C. ABSORPTION FIELD DATA Date installed Q yZ01 7 �/ Soil rating (g.p.d./W or ftz/bdrm) `�S _ System type _ �n�' I,-CHa- Length 0/( Width —3— Gravel thickness below pipe _ e � Total depth 1Zi _ Effective absorption area /226 dd Monitoring Tube present (YM) - 1 Depression over field (YM) Date of adequacy test _ U 2d 95 Results (Pass/Fail) _09,4 E S For bedrooms Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.): yl V2 Fluid depth / (ins) Minutes later: 9`/ 1wtt,5 Absorption rate = 3 d d g.p.d. Peroxide treatment (past 12 months) (Y/N) /) If yes, give date 72-026 (Rev. 3/96)* e lQ dVS4n � 4 veal level D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES "Pump on" *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Size in gallons "Pump off" level at* Septic/holding tank on lot 741 On adjacent lots /OD' '- Absorption field on lot 91, On adjacent lots _ /00 Public sewer main Sewer /septic service line DD / Public sewer manhole/cleanout /2 — � Lift station � SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: 100 1 +_ Foundation 37 / Property line Absorption field 16 Water main/service line Surface water/drainage /Do i- Wells on adjacent lots /66 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /0 1 — Building foundation 15'-7 / Water main/service line 2,5' 1'i' Surface water /06 1A' Driveway, parking/vehicle storage area 25 14 - Curtain Curtain drain (2 0 1 '_ Wells on adjacent lots _ A00 I*' F. ENGINEER'S CERTIFICATION 1 certify that l have determined thru field inspections and review of Municipal recwds�h{ Jhe_Zb%systems are in conformance withMOA HAA guidelines in effect on this date. n pq��� o...^®_�.@+° _ t 2 eq ••O oa FSS ®„�� Signat � ,, Engineer's Name Q.,1 ,go,, q �a Ken4efn M. u u _ F Date 03 Z Z �� ®p ck 7its HAA Fee .$ eq 0 - Date of Payment �`� � -z) Receipt Number ©/ ems_ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment _ Receipt Number MArIIR 22 199. �1,:03AN NTL RNCHORRGUSTING LAB, FAX N0. 19074563125 P.2/z, 01 Lill A MAR 22 '99 08.40AM NORTHERN TESTING LABORATORIES, INC. 3,430 INDUSTRIAL AVENUE FAIROANKS, ALASKA 99701 19071 656.'3116, FAX 4563125 tl005 SCHOON 87REET ANCHOTTAGC, ALASKA 98818 10071340-1000, FAX 349.1016 POUCH 340043 VIJU01IOl 11AY, Al ASKA 99734 (9071669-2146, FAX 009-2140 ,I KND Enginearing 20441 Ptarmigan Blvd Eagle River AK 99577.3736 Attn: - Our Lab #: Location/Project: Your Sample 2D: Sample Matrix: Comments: F183512 Siefker 5/D 'rr. 16 Water Report Date: 03/22/99 Date Arrived: 03/19/99 Date Sampled: 03/19/99 Time Sampled- 1000 Collected BY: HMW MRL = Method,Reporting Limit * Flag Definitions B = B01OW Regulatory Min. R Above Regulatory Mak, Digest Date Lab# Method Parameter Units Results * MRL Prepared Analyzed ------"----- . F193512 EPA 300.0 Nitrate -N 2-74 0.06 03/19/99 Reporte y1 Cindy L. C11;r ian Laboratory Director Municipality ®f Anchorage January 11, 1988 P.O. B� , 196650 ANCHORAGE, ALASKA 99519-6650 (907)343-4200 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Alan C. Wien Engineering Technician Alaska Environmental Control Services, Inc. 1200 West 33rd Avenue, Suite B Anchorage, Alaska 99503 Subject: Conditional Waiver Approval for East 1/2 of Tract 16 Si.efker Subdivision Waiver Number WR87-075A Dear Mr. Wien: The conditional waiver approval for the subject lot has been given a full approval at this time. This waiver applies to separation distances from the well to absorption area and septic tank of 70 and 91 feet respectively. The installation of the new 1000 gallon steel tank and calder couplings on the inlet and outlet should prevent effluent from exfiltrating into the ground and well. This waiver applies to this well to septic system separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Si cerely, Daniel J. Roth Civil Engineer On -Site Services cc: Gus Andress, P.E. Manager., On -Site Services/Water Quality Programs A EC s ALASKA NUIROWnTAL COnTROL SRUS, IX Q 6ngineerinq & 6nuironmenial Studies January 6, 1988 Municipality of Anchorage Department of Health & Human Services 825 L Street Anchorage, AK. 99507. Attn: Dan Roth Re: East. 1/2 of Tract 16, Siefker Subdivision On 1/5/88, the existing plastic septic tank was exposed for. inspection. The excavator, Dean Construction, reported it to be collapsed. On 1/6/88 this tank was removed, crushed and buried and replaced with a now Greer 1,000 gallon, steel, 2 compartment tank set in the same location per your 12/9/87 waiver letter. Inlet and outlet are equipped with calder couplings. A cleanout was installed after the tank. Distance from the well is 70 feet. See attached site plan diagram. We request that you issue final approval for the subject lot. If you have any questions, please call. Approved by: OF AliA�{ryJ'°k 10 ol° W *° , °� •. ne•ea••eu••°.er•//� OY C, REID, JR. °. CE -?.251 •• q,`yeY � •° Y• !PJ /rF Sincerely, 2, P w`_ J - Alan C. Wien Engineering Technician MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JAN 8 111 i? q INJUNC), 1200 West 33rd Auenue, Suite B • Anchorage. Alaska 99503 • (907) 561-5040 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY H87 -0592A 264-4744 2. TYPE OF RESIDENCE Single-Family)ax Number of Bedrooms two (2 ) 3. WATER SUPPLY Individual Well Ox Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite KX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (aev 8/86) Front Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) J 01 (a) Legal Description (include lot, block, subdivision, section, township, range) E%2 Tract 16 Siefker Subdivision M2N R3W Section 21 Location (address or directions) 3535 East Huffman Road (b) Property Owner Alaska Housing Telephone: Home Business Mailing Address PO Box 10120, Anchorage, Alaska (c) Lending Institution Centrust Mortgage Telephone Mailing Address 4000 Old Seward Highway (d) Real Estate Company and Agent Judy Upton % Re/Max Address 276-2761 Telephone (e) Mail the HAA to the followina address: or: Check here 13, if hold for pick up. List contact person and day phone number below. A.E.C.S., Inc. 2. TYPE OF RESIDENCE Single-Family)ax Number of Bedrooms two (2 ) 3. WATER SUPPLY Individual Well Ox Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite KX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (aev 8/86) Front 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm A. E. C. S . , INC. Telephone 561-5040 Address 1200 West 33 Avenue Suite B Anchorage, Alaska 99503 Date Engineer's Seal This department has received written confirmation from the engineer regarding the Conditional Approval of December 9, 1987. The corrections have been accomplished and an inspection has been completed by the engineer. The subject property meets with Muncipal standards is now approved. 6. DHHS APPROVAL Approved for bedrooms by Aate - Approved ­'&­_ Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Department of Health and Human Services (DHI-IS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (Rev 8/86) Back ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 �i JOB E SHEET NO. CALCULATED BY CHECKED BY - Of - DATE DATE_ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL �V 6J_Nj�c OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) 3S3S E«� (b) Property Owner'7¢DK �{.c.s�dh' Telephone: Home — Business Mailing Address- (c) ddress (c) Lending Institution Telephone Mailing Address /C " `A4 (d) Real Estate Company and Agent' HA x Sa�� Address Telephone z76`ZiG (e) Mail the HAA to the following address: or: Check here if hold for pick up. List contact person and day phone number below. '40g3 w/u- Ple e N)'. 2, TYPE OF RESIDENCE Single-Familyll Number of Bedrooms 3. WATER SUPPLY Individual Well'( Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite, Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (Rev 8186) Front E r/z T�+t7- /(- 5. L 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. , Name of Firm S Telep,A,ho//ne Address -1T?a 33� 3u/79- D /`tom /9K Date /- Y -,y :Z 6. DHHS APPROVAL Approved for 2 - Approved Approved 7,? -<d 3 yr,�yrs,r►�,� 0 I t ••*see •••• ..11..1,• ••••� • ROY C. REID, JR. M A.0 CE -22 P914ee�s� eal bedrooms by Po 4� Date 12 - / - 617 Disapproved Conditional X Terms of Conditional Approval 120AIFY TD Of ESCROWW TO PuR(f1AfE 4,V.9 LNELUL A STEEL SEPTIC rIV,4. 09r19IN TWO EXCAvATOrff 91DI . CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State o_f'Alaska. The DHHS doesthis as a courtesyto purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (Rev 8/86) Back I C'r. +�\�10� OF ANCHORAGE (MOA) M�tU 0 �H AUTHORITY APPROVAL (HAA) EN,iv GIJE ST - FEBRUARY 1984 264-4744 Qal Description: A. WELL DATA %P.4t7- /(a Well Classification /pe/yAne If A, B, C, D.E.C. Approved (Y/N)A1114 Well Log Present (Yo — Date Completed u'` eA)rOO,41 Yield 4 r r Total Depth / &5' Cased toG �� Depth of Grouting tAJ'ZA_ Static Water Level n� /? I Pump Set At Casing Height Above Ground 1.3 / Sanitary Seal on CasingY N) Electrical Wiring in ConduitoYN) Depression Around Wellhead (yo Separation Distances from Well: /H Id T k on Lot Lo On Adjoining Lots 11 "" -A To Septic o ing an To Nearest Edge of Absorption Field on(Lot 7 On Adjoining Lots To Nearest Public Sewer Line IA To Nearest Public Sewer Cleanout/Manhole _ 1J10 To Nearest Sewer Service Line on Lot Water Sample Collected by XE0 / ^f _ ; Date Water Sample Test, Results '04 Comments L / IVCCi Z_e /// ij 13. SEPTIC/HOLDING TANK DATA Date Installed 9-7-7% Size �D No. of Compartments Standpipes &) Air -tight Caps(ON) Foundation Cleanout (Y® Depression over Tank (Y9 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) for %} /� Temporary Holding 114Holding Tank High -Water Alarm (Y/N) 9 Tank Permit (Y/N) A) Separation Distances from Septic/Holding Tank: / To Water -Supply Well /� To Building Foundation To Property Line ro -7�' To Disposal Field To Water Main/Service Line — /y r Course o -o Comments Page 1 of 2 72-026 (RPv 8/86) Frons r 4- To Stream, Pond, Lake, or Major Drainage ,E- %y T-.r,*C r 16 sig<e C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 33o Type of System Design Date Installed 7-7-79 Length of Field �� r r Width of Field 3 � Depth of Field /Z r Gravel Bed Thickness Square Feet of Absorption Area Standpipes PresentoYN) Depression over Field (Y& Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well rj� To Property Line To Building Foundation To Existing or Abandoned System on ��� Lot _ r ; On Adjoining Lots - /a ,A - To Water Main/Service Line /0 To To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course fob r 711- `To ToDriveway, Parking Area, or Vehicle Storage Area /® /r Comments D. LIFT STATION led Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments — Dimensions Manhole/Access (Y/N) "Pump Off" Level at — Vent(Y/N) during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I ha ec ' d,verif d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 4 — Dale Company ��'G5 MOA No. OF 4b�� .'e, ' •soaae j•� �I, Receipt No. ~ O 0 ��-/- 0 c') /, ��Q+o • •,•��, Date of Payment 0O ,C Amount:$ /�O '°'1� • E•gl••®• Seal •�•• E 4 dwi2tLUA 3 V000 Page 2 of 2 72-026 (Rev 8186) Back � sa a.aa• sae aaeaoaoa no ••a� OY C. REID, JR. e° 9 9� CE-- - 2251 Munlc1pca.iity of Anchorage December 9, 1987 P.O. B(_ 196650 ANCHORAGE, ALASKA 99519-6650 (907)343-4200 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Alan C. Wien Engineering Technician Alaska Environmental Control Services, Inc. 1200 West 33rd Avenue, Suite B Anchorage, Alaska 99503 Subject: Waiver Request For East 1/2 Tract 16 Siefker Subd. Waiver Request Number WR87-075 Dear Mr. Wien: Your request for waiver of the required separation of a residential absorption area and septic tank to a private well has been granted a conditional approval at this time. This waiver will apply to separation distances from the well to absorption area and septic tank of 70 and 91 feet respectively. To obtain final approval you must check the integrity of the existing septic tank and verify that water tight couplings are in place on the inlet and outlet. If these conditions do not exist then the septic tank and/or connections will have to be upgraded to get final approval from this department. This work needs to be accomplished within thirty(30) days of the date on this letter. If you have questions regarding this matter, please direct them to me by calling 343-4744. sincerely, Daniel J. Roth Civil Engineer On -Site Services cc: Gus Andress, P.E. Manager, On -Site Services/Water Quality Programs A EC s ALASKA NUIROMMAL COnTROL SeRUICeS, MC. a Engineering & 6nuironmental Studies N�JIdIC;IPA�1lY OF hNCr10RAG pIVIS10N December 1, 1987 �NP/,EN1A� 51 VICCS ENVIz Municipality of Anchorage is Department of Health & Human Services 825 L Street Anchorage, AK. 99501 e Re: E1/2 Tract 16, Siefker Subdivision The separation distances from the well to septic tank and trench are 70 feet and 91 feet respectively. MOA records show the inspection was disapproved due to these distances and a note was made to get a waiver from Kyle Cherry of ADEC. ADEC has no record of any such waiver, however, the sewer asbuilt was approved by Bob Pratt on 9/7/79. Per the attached well drillers report, the well is 65 feet deep and cased to the bottom with a static water level of 49 feet. The well is located in the house. The sewer system is downhill from 'the well. Water samples are satisfactory. The soil is an SM with a percolation rate of 60 min/inch. This type of soil will provide excellent filtering of the effluent. We request that you grant a current waiver of the above listed separation distances as previously approved by MOA. If you have any questions, please call. Sincerely, Alan C. Wien Engineering Technician Approved by: 0 C#! • •B'� j••• •i D ••.ii• •n0Yp /�' I �i• OD ♦ •46•pnOr D ••�By° IEROY C. REID, ®O CE - 2251 b tAL' 1200 West 33rd Auenue, Suite B 9 Anchorage. Alaska 99503 9 (907) 561-5040 Alpine Drilling & Enterprises INVOICE Domestic — Commercial N° 2420 Pump & Water Systems RID Box 110496 Job Name I Location Anchorage, Alaska 99511 11:-y911c- (907) 345-0202 Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory repletion of the Above Described Work.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS, I -! PHONES— VV 1—,5'0 cA DATE — IRO�7 QUANTITY DESCRIPTION AMOUNT A (e i LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR12 vci WORN ORDERED DY DATE OOMP TOTAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory repletion of the Above Described Work.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS, I CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 LABORAT. _w �s\ FEDERAL TAX ID # 92-0040440 A'q)or V(t': . A S >cmr'a&»2G. 8 4: 6r: Rr«ws Ka m» i ts R h a! Irl'Al uct lun. .vo A0 p I , I I ! 0. a SiEFCE ,-iENVIRON....aNiAI JOB %y 7,e,4c . . ROL SERVICES, INC. SHEET NO. OF Nest 33rd Avenue, Suite B 4CHORA6E, ALASKA 99503 CALCULATED BY DATE (907) 561-5040 ^„ DATE_