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SAN JrLAQUIN COUNTY Page 1 <br /> ERVIRONMENTAL HEALTH DEPARTMFS <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209) 468-3420 <br /> INVOICE AccountlD AR0001456 <br /> Facility ID FA0001457 <br /> Date Printed 2/5/2004 <br /> COLLEGEVILLE MARKET & CAFE RE : COLLEGEVILLE MARKET &CAFE <br /> 13521 E MARIPOSA RD 13521 E MARIPOSA RD <br /> STOCKTON, CA 95215 STOCKTON, CA 95215 <br /> OWNER : LUKOSE, JOSEPH <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0116952---Date of invoice: 214/2004 <br /> 2/4/2004 2244 2004 HAZMAT FEE $ 115.00 <br /> 2/4/2004 2301 UST STATE SURCHARGE $ 15.00 <br /> 2/4/2004 2301 UST STATE SURCHARGE $ 15.00 <br /> 2/4/2004 2360 ADDITIONAL UST $ 125.00 <br /> 2/4/2004 2362 UST FACILITY&1 TANK $ 500.00 <br /> 2/4/2004 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total tar this Invoice $ 794.00 <br /> Payment Due Date 3/6/2004 <br /> TOTAL DUE this Billing Period $ 94.00 <br /> PAYMENT <br /> RECEIVED <br /> FEB 2 7 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <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 DES/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 /> 5255.rpt <br />