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JUIN COUNTY Page 1 <br /> OMENTAL HEALTH DEPARTMENT <br /> TAZELTON AVENUE " <br /> .1KTON, CA 95205 - <br /> me: (209)468-3420 = T_ <br /> C s Account ID AR0029524 <br /> INVOICE <br /> -- - Facility ID FA0016663 <br /> Date Printed F 2/2/2016 <br /> FUEL DELIVERY SERVICES RE : FUEL DELIVERY SERVICES <br /> 4895 S AIRPORT WAY 4895 S AIRPORT WAY <br /> STOCKTON, CA 95206 STOCKTON, CA 95206 <br /> OWNER : VAN DE POL ENTERPRISES INC. <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0276792---Date of Invoice: 2/2/2016 IIIIIIIIIIIIIIVIIVIIIVII VIIIIIIIIIIIVIIVIIIVIIIIIIIIIVIIII VIII <br /> 2/2/2016 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 35.00 <br /> 2/2/2016 2832 AST FAC 10 K-</=100 K GAL CUMULATIVE $ 675.00 <br /> 2/2/2016 APSA APSA SURCHARGE $ 26.00 <br /> Total for this Invoice $ 736.00 <br /> Payment Due Date 3/3/2016 <br /> TOTAL DUE this Billing Period $ 736.00 <br /> IVED <br /> FEB 17 2016 <br /> ENVIRONMENTAL <br /> {-IFA I TM r1F04 RTIAFNT <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 HMBP 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 />