HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 7 LT 5
Municipality of Anchorage Page _ /
DEPARTMENT OF HFALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well ~nspection Report
Permit Number: ~',~:~'-- PID Number:_ ~l~
upgrade
[¢.4j~C..CTj~ ~. ~~ Wastewater System: D New
~"~ .~.~ ~. ~¢~ ABSORPTION FIELD
Phone: ~~ l~o. ol~ooms: D Deep Trench Q Shallow Trench ~ed DMound ~Other
LEGAL DESCRIPTION Soi,,~tin~: D'~/S,.~h To~O~,th~ro.,o,i,i.~,.~e:
Lot: ~ Block: ~ ~~~Subdivision: ~3eplh t0 pipe bottom from origin~l~,grade:/~ Ft. Gravel depth benesth pipe ~
Tow..h,.: J..n..: ' ]"~,,¢.: .,,,~.~o.~or,.,,,~,.,.~.: , ~r.w,,..¢h: .
Number of lines: ~ Distance between lines:
WELL: D New D Upgrade Gravel~:~t~}, ~= J~ ~/Ft.
Classification (Private, A,B,C): Total Depth: CaseCTo: Total absorption area: Pipe material: ~1
_~ ~ ~~ Ft. Ft. _~l~aO, Ft. ~
~r,,~e,: ..,.~r,,,.~: ~,~,ioW~,~,~.~,:~,. ,n.,.,,.,:~M~. .~,.,n.,.,,.~/~
=Yield: GPM ~ Pump Set at: Ft. ~ Casing Height Above Ground:Ft. TANK
SEPARATION DISTANCES ~Septic D Holding B S.T.E.P.
TO Septic Absorption Lift Holdfng ~ublic/Private M nufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~~ ~
s.~Oew~t.r J¢D~ lOO'-r ~ ~ ~ LIFT STATION
- ]
Lot Size in gallons: Manufacturm:
Line ~/ ~l
Foundation ~ / ~/ ~ "Pump on'~ ~~ level al: water alarm at:
Curtain Pump M~d~ ~El~tri~ll~p~tions performed by:
R~marks: B~NOH ~ARK
Assumed Elevation:
E~GIN~ER'S SEAL
Department of Health an~ Hi,man S~r~s approval t~,,,.
~i~w~a a,~d ~pp~o~ed by:~ ~t~: ~~
72-013 (1/91) MOA 25
P e r mit N o. ~~?~?--~- Page_ ?.--~---_of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,O, Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: ~L...-~?..-~.--, -Tjx',, ~ ~ PIDNo.: 4:~1~10'~0¢
72-013 A (2/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM
PERMIT NUMBER:SW920002
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:GORECKI RICHARD W
OWNER ADDRESS:9540 ARLENE RD.
ANCHORAGE, AK 99515
PARCEL ID:01910205
LEGAL DESCRIPTION: SKYWAY PARK ESTATES BLK
5
7 LT
(UPGRADE) PERMIT
DATE ISSUED: 1/13/92
EXPIRATION DATE: 1/13/93
LOT SIZE: 101451 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ISSUED BY: ---
DATE:
DATE:
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
OISPOSAL SYSTEM
DESIGN
January 7, 1992
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, Alaska 9950].
REFERENCE: Skyway Park Estates Subdivision: Block 7; Lot 5
Request you issue a permit to upgrade the septic system
serving the referenced property.
One test hole was excavated by S & S Engineering in the area
of the proposed upgrade, and two percolation tests were
performed. Water monitoring was performed with the monitoring
· tube which existed in the Kniefel test hole (attached is
Kniefel's soil log). The proposed upgrade design is attached.
The above referenced property is served by Municipal water.
We do not anticipate any adverse effects on neighboring
properties by the installation of the proposed septic upgrade.
If you have any questions or require additional information
for your review, please contact us.
Sincerely,
ROGER J. SHAFER, P.E.
RJS/lsu
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
10-
~,, 11
DATE PERFORI
Township, Range, Section:
14¸
15-
16
17
18-
19-
SLOPE
ENCOUNTERED? . . ,
L
IF YES, AT WHAT O
DEPTH? p
E
(]epih Io Water¢llB~ ~ /
Monitoring? ~'~)~/ gato: /-~E:~
SITE PLAN
f ading D te~p Gross Net Depth to Net
-~2 ~_~[ ~ERCOLATION RATE
'~¢O':~ ~ TEST RUN ~TWEEN ~_ FT AND ~-- FT
17034 ~agle ~lver I.oep Roa~
PERFORMED BY: "--'~,~b--'~ AC -%~ ~ERTIFY THA~ THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC~ ON'THIS DATE. DATE:
72-008 (Rev. 4185)
O-
Tim~
.-Zz~ ....
P, 03 .... -'~
...... ~ GER'TI/,Y ?HAl' THI~3EBT WA~ P~.O IN
TA?EANDMUNICIPAL(~UIDFdJR~INEFFECrONll~II~DATF_ DAT~ _ '~l /'~L.~/ .....
DEPARTMENT OF HEAl.TH & HUMAN SERVICE8
O~ "L" 8trot, Anoho~age, Alaska 99502-00~0
8OII. 8 LOG -- PERCO~TION TEST
PLAN
10-
11
12
18
14-
17
10-
2(,1-
........
OLp DIAMEfEIt - ·
TFJ~T
~ ~l~ C~TIFY'THAT. THI8 ~BT WAS p~ORMEDIH
~ ~--~ MUNICIPALITY OF ANCHORAGE
~/~ ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
(_ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage. Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~'AME PHONE - NEW
MAILING ADDRESS
LEGAL DESCRIPTION
~CATION ' NO. OF BEDROOMS
Well ] Absorption area Dwelling PERMIT NO.
~ ~ Manufacturer MateriaJ No. of c~partments
Liq. capacity in 9allons Inside length Width Liquid depth
12.~O ~F ~OMEmg~:
, ~ Well DweHin9 PERMIT NO.
~ ~ ~ Mmlufacturer .... Material Liquid capa~ity~n gallons
-- ~ Well Foundation ~ ~arest lot I,ne~o, ---1 ~-~
~ ~ ~ No.DISTANCEof lines TO:.l I~' ~CO~ ~_inches PErM T NO.
-- Length of each~L, Total length ~es/ Trench width Distance b~twee.~ lines
~ Total efective absorption area
~ Top of tile to finish grade ~, Materialbeneathtile 7~ inches ~.
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
LU Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer ~ine S0ptic tank Absorption area(s)
~ DISTANCE TO:
OTHER
~IPE MATERIALS ~ ~
~OI L TEST RATING
REMARKS ~ ~¢ ~>,~ / ,
72-013 (Rev. 3/78)
PERMIT NO.
r-IUN Z C Z F"RL I T¥ OF FtI'-,IC:HORFIGE
DEPRR'rH~NT r- HEALTH AND ENVIRONHENTF~L
825 'L STREET~ RNCHORRGB
264-4720
qPPLICRNT
_OCATION
LEGAl,.
ROBERT TOMPKINS BOX 192 SAR FINCH
NO0 BLVD
I. 5 B ? SKYWAY PARK ESTt~TES LOT SIZE:
:]:44~-7600
86000 S(.~UARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXII'IUM NUMBER OF BEDROOMS = 4
SOIL RATING (SQ FT/BR).~= ~65
]'HE REQUIRED SIZE OF THE'.' SOIl_ ABSORPTION S~r'STEi"I IS:
[:' E P ]- H-~-- :::i_ [,,~ L E: I'.~! ii T i-I=~, 1.56 GRF~',/EL. [:. IS P ]"F~ =;
TME LENEiTH DIMENSION IS THE LENGTM (IN FEET) OF TME TRENCH OR DRAINFtEL,D.
TME DEPTH OF FI TRENCH OR PIT IS THE DI~]"ANCE BETWEEN THE'. SI. JRFFICE OF THE
GROUND AND THE BOTTObl OF' THE EXCAVATION (IN FEE]'),
THERE IS NO SET WIDTH FOR TRENCHE<i
THE (~RAVEL DEPTH IS THE MINIMUM DE?TH OF GRAVEl-. BETWEEN THIS OUTFRLL PIPE
AND 'FHE BOTTOM OF THE EXCAVATION (IN FEET),
PERMIT RPPL. ICRNT HAS THE.'", RESPONSIBILITY TO INFORM THIS DEPARTMENT DLIRIN(~ THE
INS'FALLATION INSPECTION.S OF ANY WELLS RD.TRCENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THRT THE HELL WILL SERVE.
....... 'Tll40 ( 2 ) I l'-.I.5 F'E~C"F I ,IbiS' FIF~E R ~'~. L-]. O~J ][ IRED ..............
BACKFILLING OF FIN~ SYS'I"I~EM WITHOUT FINAL INSPECTION AND APPROVFIL E~"r' THIS
DEPFIRTMENT WILL DE SL.IB.TECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A NELL AND ANY ON-SITE SEWAGE DISPOSAL S'~'STIEf'I IS
100 FEET FOR A PRIVATE NELb OR
'150 TO ;~00 FEET FROM Et PUBLIC NELL DEPENDING UPON THE TYPE OF FIJE, L. IC WEE.[ ....
NELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]~0 DAYS
OF THE NELL COMPLETION.
01"tJER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONS'rRUCTION DIAGRAMS ARE
RVRILRBLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
i: I AM FAMILIAR WITH Tt4E REQUIREMENTS FOR ON-SITE SEWERS AND WELLS lIS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
R: I MILL INSTALL THE SYSTEM IN ACCORDANCE HITH THE CODES,
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REI;!UIRE ENLARGEMENT IF TME
RESII)ENCE IS/,,F,~EMOD:.~,FJ~DD~INCLUDE MORE TMAN 4 BEDRCIOI'tS.
.............................
FIPPLICANT ROBERT TOMPKINS
I ~.,UED 13Y .... ~ ................. DATE_-J~..
May 24, 1978
Mr. Robert Tompkins
Box 192, Star Route A
Anchorage, AK 99502
Subject: Soils investigation for sanltary sewer system; Lot 5i>B!?qk 7, Skywayl
par~ E~it~tes, iAnchorage, Alaska.
Dear Mr. Tompkins
At your request of May 10, 1978, I conducted a soils investigation at the proposed
location of a sanitary sewer system on the subject lot.
This investigation, which was accomplished on May 23, 1978, consisted of the
inspection of soils removed during drilling with a trailer mounted Mobile B-34,
using 4" diameter solid flight augers, to a total depth of 17 feet.
The topography of the area where the soils test was conducted, is flat and level,
with no discernable drainages. Vegetation in the in~edtiate area consisted of tall
and generally slender birch trees in a moderately dense stand, intermixed with some
spruce, with moderately dense willows near the road, and included a ground cover of
grasses and mosses.
The soils encountered are graphically shown on the accompanying test hole boring
log. The soils consisted of a silt with some clay and organics ( 6 inches thick ),
overlying silty gravels with some sand, gravelly sand with some silt, and sandy
gravel with some silt to a depth of 17 feet. These soils are all classified as
~M type soils, except for the top 6 inches. Numerous cobbles were encountered
during drilling from a depth of 6 inches to 17 feet.
No water table was encountered.
A percolation test was performed on the test hole. The results are tabulated on
an accompanying sheet.
An accompanying sketch shows the subject lot with the approximate location of
the test hole in relation to the property lines.
I appreciate the opportunity to be of service to you. Please contact me if you
}]ave any questions regarding this soils investigation.
Very truly yours,
Consulting Geologist
Box 191, Star Route A
Anchorage, Alaska 99502
(907)344-9150
xc: Dept. of Health & Envirorm%ental
Protection
Attachments: Drawing of test hole boring log with locatlon sketch, and tabulation
of percolation test results.
May 24, 1978
Robert Tompkins Property
Lot 5, Block 7, Skyway Park Estates,
Anchorage, Alaska
Percolation test on Test Hole No. 1
TABULATION OF PERCOLATION TEST RESULTS
TIME ET(min) INCHES DROP
].4:06 Start 2.0" Start Start
14:12 6 6.5" 4.5" 1.3
2.4:20 8 8.0" 1.5" 5.3
14:29 9 9.0" 1.0" 9.0
14:36 7 9.5" 0.5" 14.0
14:51 15 11.5" 2.0" 7.5
15:00 9 12.0" 0.5" 18.0
15:06 6 12.4" 0.4" 15.0
RATE(rain per inch)
Average percolation rate for entire hour = 5.8 minutes per inch
Average percolation rate for last one half hour = 10.3 minutes per inch
Michael B. Bergmann
Consulting Geologist
Anchorage, Alaska
.¸7
MUNICIPALITY O1" ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~.~ (~-'~
OF ON-SITE SEWER AND WATER FACILITY ' :
264-4720 ,
Application Date _J / 2 ? / ~ "7
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name -~'¢~¢'~f' r~ ¢6/v Telephone: Home "~ ¢/g "~3¢'~'"' Business
(c) Applicant is (check one): Lending InstitutiOn []; Owner/builder [~'; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e)
(f)
Real Estate Company and Agent
Address '~ ¢~'(P (--) ~'0¢'¢/¢J¢'~ "~'~.,,.
Telephone ~, 7~- ~
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~-,
3, WATER SUPPLY
Other
Individual Well [] Community [] Public [~ . , ~' '
Note: If community well system, must have written confirmation from the State Department ~(Environ mental C~nservation
attesting to the legality and status, .
SEWAGE DISPOSAL
Onsite [] Public [1 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 (1~/84)
ENGIr~EERING FIRM PROVIDING INSPECTIONS, TESTS~ FILE SEARCH, DATA AND INFORMATION
As certified by my seal atfixed hereto and as of the validation date showu below, I verify that my investigation of this Fiealt h
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 d~sposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspeclion.
Nameo[Firm ~1~ ~c~,~o[ ~C~_Telephone . ~/~- /~-~
Address _
Date
Engineer's Se.al
Approved for ,~/~/'/,¢) ~_ )edrooms by
Approved ~..~/'~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
aaalyze 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 {11/84)
NORTI ERN TESTING LABORATORIES, INC,
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115
6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99918 907-349-8623
Drinking Water Analysis Report for Total Colifarm Bacteria
TO BE COMPLETED BY CLIENT
PRIVATE WATER SYSTEM
,
Mailing Addres
CiW State Zip Code
SAMPLE DATE: I "~,.3 E, 7 Phone ~, ~¢~'-'l ~5~'
Mo. Day Year
Purchase Order No.
SAMPLE TYPE:
I~ Routine
[] Special Purpose
[] Check Sample (for original contaminated
sample with lab reference no.
[] Treated Water
[] Untreated Water
.)
Sample Time
No, Location Collected Collected by
8
9
10
Signature of Representative
FOR LABORATORY USE ONLY
1'O BE COMPI.~T,~,D SY LABORATORY
Received at:~fl~ Anch. [] Fbks,
Date Received
'rime Received ._ /~:'~/~
Next Sample Dee
COMMENTS:
SATISFACTORY (~
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
Count LSB BGB Result*
To_~Colifor m Colonies
Time
per 100 mis.
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Descripeon: [.,,~'~, f~ '7,
MUNICIPALITY OF ~,NCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
N 2 ? 1987
RECEIVED
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth~
Static Water Level
Casing Height Above Ground
Electrical Wiring n Conduit [Y/N) _
Separation Distances from Well:
To Septic/Holding Tank on Lo~ ~ ~(/"1
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line NJ R
Cleanout/Manho~e
Water Samole Collected by 'T'
_ Cased to ~ ,5'~"
5-0"
If A B, C, D.E.C. Approvea (Y/N)
Date Completed I? 7 r~~ Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) .
On Adjoining Lots
I$"g ' : On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
Date t / ~-.~'J
Water Sample Test Results ..;,¢/'t(.J'~¢
Comments ~ ( / ~/ ~ ~l l~
SEPTIC/HOLDING TANK DATA
Date Installed ¢'{E'/
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separanon Distances from Septic/Holding Tank:
To Water-Supply We
To Property Line
To Water Main/Service Line
Course _~> lOC'
Size 1 867:? ~fcr / No. of Compartments '~-
Air-t ght Caps (Y/N) _ ~ Foundation Cleanout (Y/N) _ ~
Date Last Pumped J t~ ~,¢'~'~ 7 ~-~
;for N, /~
Temporary Holding Tank Permit (Y/N) i~..4.
To Building Foundation _'~ ~¢'o ~
To Disposal Field ! ¢'
To Stream. Pond. Lake. or Major Drainage
Comments
Page 1 of 2
72-026{ I 1/84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ ('5- / 7 ~'
Width of Field '8 ff' ~'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
Type of System Design
Length of Field .¢u'~ '
Depth of Field I ~-. '
Gravel Bed Thickness 6' r
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water-Supply Well
To Building Foundation ~'
Lot (qr/L
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Property Line Zo '
To Existing or Abandoned System on
; On Adjoining Lots ~, '3 o ~
To Cutbank (if present) 1~¢/~.
To Driveway, Parking Area, or Vehicle Storage Area
Comments '~ ~/~,~-,?~ ~ -¢'--~ .'~.'/~,'nl~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ¢j'~'~"~- ~;L'"~g¢~,-,,~ Date I / ~6'*/~:~ 7'
Company
Receipt No. ~,~
Date of Payment
Amount: $ I~
Page 2 of 2
72-026 (11/84)
M CA No. ~ ~ -¢;¢,,,¢ ~