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Z JUTAWUIN UVUN I i <br /> ENVIRONMENTAL HEALTH DEPARTME• Page 1 <br /> 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> INVOICECOPY �y Account ID LNEOMMMMOMMMEMA <br /> AR0001916 <br /> Facility ID FA0001 009 <br /> Date Printed 5/30/2012 <br /> ELDER, FASSEL M OPERATOR RE : COUNTRY CLUB FOOD& FUEL MINI MART* <br /> COUNTRY CLUB FOOD& FUEL MINI MART* 1856 W COUNTRY CLUB BLVD <br /> 1856 COUNTRY CLUB BLVD STOCKTON, CA 95204 <br /> STOCKTON, CA 95204 <br /> OWNER : ELDER, FASSEL (PHILLIP) <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0223871 ---Date of Invoice: 1/30/2012 III11I1 IIIIVIVIIVIIIVIIVI VIII VIII VI1I1111III 1I 1111111111111 <br /> 1/15/2012 9991 Credit Adjustment ($ 98.00) <br /> 1/27/2012 2220 SM HW GEN<5 TONS/YR $ 213.00 <br /> 1/27/2012 2244 2012 HAZMAT FEE $ 85.00 <br /> 1/27/2012 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2012 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2012 2360 ADDITIONAL UST $ 125.00 <br /> 1/27/2012 2362 UST FACILITY&1 TANK $ 550.00 <br /> 1/27/2012 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 1/27/2012 ERSC ELECTRONIC REPORTING STATE SURCHARGE FEE $ 25.00 <br /> 3/15/2012 9987 Haz Mat Program Penalty Fee $ 8.50 <br /> 4/15/2012 9994 PERMIT FEE PENALTY $ 115.00 <br /> 4/15/2012 9994 PERMIT FEE PENALTY $ 550.00 <br /> 4/15/2012 9994 PERMIT FEE PENALTY $ 125.00 <br /> Total for this lnvo(ce $ 1,752.50 <br /> PAST DUE <br /> TOTAL DUE this Billing Period $ 1,752.50 <br /> PAST D U E <br /> Delinquent charges <br /> will be forwarded to <br /> COLLECTIONS <br /> in 30 days. <br /> Please make Checks PAYABLE to: 'EHD' — Return a Copy of This STATEMENT with Your PAYMENT <br /> Penalties will be added to all Permit Fees For DES/HMMP Fees For all SERVICE FEES <br /> at the Rate of 100%of the Base Fee Penalties will be added at the Rate of 10% Penalties will be added at the Rate of 10% <br /> 30 Days after the Due Date 45 Days after the Invoice Date 60 Days after the Invoice Date and each 30 Days thereafter <br />