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<br />~E~~(~ I ~YIC.~ l ~F •r~~ <br />a: <br />etiti~ei Selected Pr~~ect: C®mrnercia! Aricult~ral and industrial Processes ~AtP~ <br />Technical ~e~iew Fee <br />Application: CI 27 - <br />Patrick Cox <br />City of Eugene/City f ngineer <br />99 E Broadway Suite 40Q <br />Eugene, QR 97401 <br />Additional Review Charge: $9,3~4.0~ <br />Payment due by: August 1~, X015 <br />Payment Method: <br />. ❑ Check; please make your check payable to the "Qregon department of Energy" and <br />include the check with this form. <br />❑ visa f MasterCard: <br />l~i~a i~asterCard Qiscover <br />All FIELDS RE UIREQ TD PRQCESS: <br />Credit Card Number; E~piratian Date; <br />Name of cardholder as shown on credit card: <br />Security Code digits on bacl~ of card): <br />Billing Address for the card. Grp, <br />Email Address for receipt: <br />Cardholder Signature: Date: <br />Credit card information iii a estroye once the payment is racesse o <br />Please return this f®rm with payment or payment inf~rrr~ation toy <br />Qregon Department of Energy ~ CAIP - <br />PQ Box ~OflB <br />Salem, QR 9?~0~ <br />