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UNDERGROUND TANK <br /> BILLING STATEMENT <br /> COMP #: TOTAL # OF ACTIVE TANKS <br /> AT SITE: <br /> SWEEPS: YEARLY FEES: <br /> PERMIT IFSUED: <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> BILLING ADDRESS: <br /> CITY: ZIP: <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 /> #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 /> * State Surcharge due this year <br /> EH 23 0 10/89 ACCOUNT RECORD <br />