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UNDERGROUND TANK <br /> ' BILLING STATEMENT <br /> COMP #: 1 C 1-�.>; — TOTAL # OF ACTIVE TANKS <br /> AT SITE: 'y <br /> SWEEPS: ` YEARLY FEES: r � <br /> PERMIT ISSUED: <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> BILLING ADDRESS: 3 <br /> CITY: T t 0,r,' ZIP: <br /> k , <br /> TANK # SIZE/CONTENTS DATE SURCHARGE NEW TANK DATE <br /> SURCHARGE PD DUE TANK REMOVED SURCHARGE <br /> DATE RELEASED <br /> #1 <br /> #2 <br /> #3 <br /> #4 <br /> #5 <br /> #6 <br /> #7 <br /> L#9 <br /> #10 <br /> * Total State Surcharge Due: Pay this amount. <br /> Tank Fees: $100 . 00 per site 30. 00 plan check <br /> 50 . 00 per tank 35. 00 per hour inspection <br /> 56. 00 State Surcharge 5 yrs 52. 50 overtime inspections <br /> 90 . 00 closure fees per tank <br /> CURRENT FEES: <br /> YEAR TOTAL AMOUNT OWED TOTAL AMOUNT PAID IF SURCHARGE PAID <br /> DA'Z'E PD/DESCRIPTION THIS YEAR INDICATE <br /> OF PAYMENT TANK # <br /> 1989 <br /> 1990 �-� D la <br /> 1991 <br /> 1992 <br /> 1993 <br /> * State Surcharge due this year <br /> EH 23 0 10/89 ACCOUNT RECORD <br />