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JANJUAQUIN LUUNI Y <br /> ENVIRONMENTAL HEALTH DEPARTM"^IT Page 1 <br /> 600 E MAIN STREET y <br /> STOCKTON, CA 95202 ..r <br /> Phone: (209) 468-3420 COPY <br /> �f <br /> Account <br /> INVOICE AR001 se7o <br /> lD <br /> J .. <br /> Facility ID FA0009870 <br /> LMUMMEMEMOMMI <br /> Date Printed 4/28/2011 <br /> FOREST LAKE GOLF COURSE RE : FOREST LAKE GOLF COURSE <br /> 2450 E WOODSON RD 2450 E WOODSON RD <br /> ACAMPO, CA 95220-9646 ACAMPO, CA 95220 <br /> OWNER : MARGARET J RING <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0211849---Date of Invoice: 1/31/2011 II IIII I IIIV II VIII VII VII V VI IV II II 11 I I II II 1111111111111 <br /> 1/28/2011 2244 2011 HAZMAT FEE $ 315.00 <br /> 1/28/2011 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 1/28/2011 ERSC ELECTRONIC REPORTING SURCHARGE $ 25.00 <br /> 3/20/2011 9987 Haz Mat Program Penalty Fee $ 31.50 <br /> Total for this Invoice $ 395.50 <br /> Payment Due Date 3/2/2011 <br /> TOTAL DUE this Billing Period $ 395.50 <br /> 4 UA WQ <br /> Oehl q1-.!c-rt ha ges <br /> will be icyVecaqr�e <br /> g,;.,. it 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 /> 5254.rpt <br />