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OAN JUAVUIN %,UUN I T Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTM!"T <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209)468-3420 <br /> INVOICE AC untID , R 0184 <br /> Facility ID F FA00 00185 <br /> Date Pnnted 1/26/2007 <br /> B ANDERSON, LICENSES/PERMITS RE : CIRCLE K STORE #1205* <br /> CIRCLE K STORE#1205* 16470 CAMBRIDGE ST <br /> 495 E RINCON ST STE 150 LATHROP, CA 95330 <br /> CORONA, CA 92879 <br /> OWNER : CIRCLE K STORES INC <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0157474--Date of Invoice: 1/25/2007 IIIIIIIIIIIIIi VIIVIIIVII VIIIIIIIIIiIIIIIIIIIVIIIVIIIIIIII 111111111 IN <br /> 1/25/2007 2220 SM HW GEN<5 TONS/YR $ 206.00 5`j3 <br /> 1/25/2007 2244 2007 HAZMAT FEE $ 270.00 <br /> 1/25/2007 2301 UST STATE SURCHARGE FEE $ 15.00\ <br /> 1/25/2007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/25/2007 2360 ADDITIONAL UST <br /> $ 125.00 3311 <br /> 1/25/2007 2362 UST FACILITY 81 TANK $ 500.00,50 <br /> 1/25/2007 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 351 <br /> Total for this Invoice $ 1,155.00 <br /> Payment Due Date 2l 007 <br /> TOTAL DUE this Billing Period $ 1 155.00 <br /> PAY <br /> RET <br /> E��VED <br /> 14,11 FEB 0 9 2007 <br /> ENVIROVM CpUNrr <br /> HEALTH DEPART y)EMr <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 I I;Jg2L) <br /> I-I-O-1 12-3 1-01 <br />