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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT . Page 1 <br /> 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Phone: (209)468-3420 <br /> AMENDED AR�0040�326 Account ID I <br /> INVOICE <br /> Ns,,i YSC®ICE `llllll� <br /> Facility ID FA00221.10 <br /> Date Printed11/8/2017 <br /> ATTN: OPS LICENSING RE : GOLDEN STATE FC LLC (OAK4/6) <br /> LANCE JONES 1555 N CHRISMAN RD <br /> 345 BOREN AVE N TRACY, CA 95304 <br /> SEATTLE, WA 98109 <br /> OWNER : GOLDEN STATE FC LLC <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0300436--Date of Invoice: 9/26/2017 VIII III VIII VVIVIIIIIIIIIIIIIVIIIIIIIIVIIII <br /> 9/26/2017 1921 HMBP-Regular-Primary Location $ 738.00 <br /> 9/26/2017 1922 CERS Processing Fee $ 25.00 <br /> 9/26/2017 2247 RCRA GEN 5<25 TONS $ 1,949.00 <br /> 9/26/2017 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 49.00 <br /> 9/26/2017 APSA APSA SURCHARGE $ 26.00 <br /> 10/26/2017 9999 PAYMENT ($ 2,787.00) <br /> 11/8/2017 2230 GEN 250<500 TONS PERMIT $ 2,496.00 <br /> 11/15/2017 9997 CORRECTION TO A CHARGE ($ 1,949.00) <br /> Total for this Invoice $ 547.00 <br /> Payment Due Date 10/29/2017 <br /> TOTAL DUE this Billing Period $ 547.00 <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 60 Days after the Invoice Date 60 Days after the Invoice Date and each 30 Days thereafter <br /> 5254.rpt <br />