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COMPUTER # (Yl R C O ry') LA <br /> DBA <br /> PREMISE ADDRESS: O <br /> BILLING NAME: <br /> BILLING ADDRESS: <br /> FEE INFORMATION: <br /> DATE AMOUNT PAID SURCHARGE FEE MISC, / DESCRIPTION <br /> - $ $ $ <br /> $ <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 APPROVED SURCHARGE FEE RELEASED IT/ <br /> J) <br />