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UNDERGROUND TANK <br /> BILLING STATEMENT <br /> COMP E�z u TOTAL # OF ACTIVE. TANKS <br /> AT SITE: <br /> • <br /> SWEEPS: _--1 — YEARLY FEES <br /> PERMIT ISSUED: <br /> FACILITY NAME: QL� d <br /> FACILITY ADDRESS: C� <br /> BILLING ADDRESS: <br /> CITY: P_ C,� ZIP:q:�!5 <br /> ANK # SIZE/CONTENTS DATE SURCHARGE NEW TANK DATE <br /> SURCHARGE PD DUE TANK REMOVED SURCHARGE <br /> DATE ELEASED <br /> #1 <br /> -ate -� b ��• .. <br /> #2 <br /> #3 <br /> #4 <br /> #5 <br /> #6 <br /> #7 <br /> #8 <br /> #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 /> DATE PD/DESCRIPTION THIS YEAR INDICATE <br /> OF PAYMENT TANK # <br /> 1989 <br /> 1990 CMZ <br /> b• ��h. �l i -� <br /> 1991 0�(550 -a5-� 1 / �1�. N ,1-- <br /> 1992 <br /> 1993 <br /> * State Surcharge due this year <br /> EH 23 0 10/89 ACCOUNT RECORD <br />