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NAME IL/�''fi1K0� UGT BILLING REC. <br /> ADDRESS <br /> CITY <br /> COMP # fv LS • /�/�Q A'Hp IU <br /> SITE FEES ($100 PER YEAR) <br /> 86 FEES 87 FEES 88 FEES <br /> STATE CLOSURE <br /> TANK # SIZE AND PRODUCT SURCHARGE O O C� 1�_ FEES <br /> z <br /> • L--=� —�=— T I7 <br /> 4 Z— <br /> 6 SAO /w L -r . i / o L <br /> 576) <br /> �; t yK?k :� •. H a,� ' .-s�ry, '`:�'. ::i7�� +ate^�'3d'd�.q ` ..: .a: k��._ <br /> 10 <br /> TOTALS PAID TO DATE <br /> SUB TOTAL OF FEES PAID <br /> ------------------------------------------- <br /> TOTAL DUE <br /> -------------------------- ---- -- -------- <br /> �� c/ <br />