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SAN;SCAdUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTbw4T y Page 1 <br /> 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Phone: (209)468-3420 <br /> Account ID AR0 442065 <br /> INVOICE <br /> Facility ID F FA0022940 <br /> Date Printed 5/20/2015 <br /> BURLINGTON STORE#828 RE : BURLINGTON STORE#828 <br /> JUSTIN KANG 1055 S MAIN ST <br /> 1830 ROUTE 130 NORTH MANTECA, CA 95337 <br /> BURLINGTON, NJ 08016 <br /> OWNER : BURLINGTON STORES <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0266190---Date ofInvoice: 5/20/2015 IIIIIII IIIIIIIVIIVIIVIIIVIIIIIIIIIIIVIIIVIIIIIIIIIIIIIIIIIIIIIIII <br /> 5/20/2015 2220 SM HW GEN<5 TONSNR $ 213.00 <br /> 5/20/2015 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 35.00 <br /> Total for this Invoice $ 248.00 <br /> Payment Due Date 6/19/2015 <br /> TOTAL DUE this Billing Period $ 248.00 <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 100% 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 <br />