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4 � <br /> SAN JOAQUIN COUNTY <br /> ENVIRON'.NIENTAL HEALTH DEPARTWNT Page 1 <br /> &30 E FAXIN STREET # <br /> STodkTON, CA 95202 <br /> Phone: (209)468-3420 <br /> INVOICE AccountID AR0037834 <br /> I <br /> Facility ID FA0021021 <br /> Date Printed 1/30/2012 <br /> MEDINA, LUIS H RE : COLOMEX MOBILE FRAME & BODY <br /> COLOMEX MOBILE FRAME& BODY 23731 S CHRISMAN RD <br /> 23731'S CHRISMAN RD TRACY, CA 95304. <br /> r TRACY,CA 95304 i <br /> l OWNER : MEDINA, LUIS H ` <br /> Date Health <br /> Program�Description <- _ _ _ Amount _ <br /> Invoice# IN0226469--Date ofInvoice: 11301202 IIIIIIIIIfIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIllllllllllfflllllffllifflllllllll <br /> 1/27/2012 2220 SM HW GEN<5 TONSIYR $ 213.00 <br /> i <br /> r <br /> 1/27/2012 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 I <br /> 1/27/2012 ERSC ELECTRONIC REPORTING STATE SURCHARGE FEE $ 25.00 <br /> Total for this Invoice $ 262.00 <br /> Payment Due Date 2129/2012 <br /> i <br /> TOTAL DUE this Billing Period $ 262,00 <br /> } <br /> 10. f <br /> p <br /> r <br /> EAL� <br /> - ENpERM�1�5 <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 OES 1 HMMP Fees For all SERVICE FEES 4 <br /> at the Rate of I GO%of the Base Fee Penalties will be added at the Rate of 10% Penalties will be added at the Rate of 10% 1 <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 /> l <br />