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COMPUTER # <br /> DBA <br /> PREMISE ADDRESS: S <br /> BILLING NAME: <br /> BILLING ADDRESS: <br /> FEE INFORMATION: S' <br /> DATE AMOUNT PAID SURCHARGE FEE MISC, / DESCRIPTION <br /> o $ a5 k $ Sly $ <br /> E `i $ $ <br /> TANK INFORMATION: <br /> TANK # ) STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> TANK # STATE ID# / STATUS <br /> FACILITY PERMIT APPR,._._D SURCH._,iE FEE RELEASED <br />