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JAN JUAUUIN GUUN I Y <br /> ENVIRONMENTAL HEALTH DEPARTMt Page 1 <br /> 600 E MAIN STREET <br /> ON, 95202 <br /> Phone: COPY <br /> Phone: (209) 46 8-3420 <br /> INVOICE Account ID IF—AR0028468 <br /> Facility ID FA0016278 <br /> Date Printed 8/24/2010 <br /> BROADBASE INC dba JIFFY LUBE RE : JIFFY LUBE#1478 <br /> JIFFY LUBE#1478 1648 E HAMMER LN <br /> 1471 SHORE ST STOCKTON, CA 95210 <br /> WEST SACRAMENTO, CA 95691 <br /> OWNER : FOWLER, DON W <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0206360—Date of Invoice: 8/24/2010 11111111111111111111IIN11111p1111111111111111111111IN IN <br /> Hrs Employee <br /> 7/27/2010 2229 306-FOLLOW UP FOR NON-COMPLIANCE 0.50 BACKUS $ 57.50 <br /> Total forthis Invoice $ 57.50 <br /> Payment Due Date 9/23/2010 <br /> TOTAL DUE this Billing Period $ 57.5 <br /> PAYMENT <br /> RECEIVED <br /> SEP 13 2010 <br /> SAN JOAQUIN COU <br /> NTy <br /> HEALTH DE ENVIRONAR M N7' <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 <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.rp1 <br />