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SAN JOAQUIN;COUNTY <br /> ENVIRONMEFc4TAL HEALTH DEPARTh 'r Page 1 <br /> "Q E I&IN'STREET <br /> I STOCKTON, CA 95202 <br /> ! Phone: (209)468-3420 <br /> 5 <br /> INVOICE Account ID AR0037834 <br /> Facility ID FA002102i a <br /> Date Printed 2/29/2012 <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 /> l; TRACY, CA 95304 <br /> OWNER : MEDINA, LUIS H' j <br /> l I <br /> Date Health <br /> Program Description. Amount <br /> invoice# 1N0226469--Date ofInvoice: 113012012 Illlllllllllflfllllllllllllllllllllllllflfllllllllllffillllfflfllllllllllli'fillfllfll ' <br /> 1/27/2012 2220 SM HW GEN<5 TONSIYR $ 213.00 <br /> 1/27/2012 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 112712012 ERSC ELECTRONIC REPORTING STATE SURCHARGE FEE $ 25.00 <br /> i <br /> Total for this Invoicel $ 262.00 I` <br /> Payment Due Date 2/29/2012 f <br /> A <br /> TOTAL DUE this Billing Period $ 262.00 <br /> r <br /> BSE <br /> A � <br /> I <br /> i ILrP <br /> Y <br /> f <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 I HMMP Fees For all SERVICE FEES 4 <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°/E <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 /> II <br /> 5254.rpt <br />