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SAN JOAQUIN COUNTY Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E HAZELTON AVENUE <br /> STOCKTON, CA 95205 <br /> Phone: (209) 468-3420 <br /> pAccount ID AR0003421 <br /> INVOICEie "'0j <br /> Facility ID FA0003833 <br /> Date Printed 1126/2017 <br /> TOM HUGHES RE : SUPER STORE INDUSTRIES - GROCERY <br /> 16888 MCKINLEY AVE DIVISION <br /> LATHROP, CA 95330 16888 MCKINLEY AVE <br /> LATHROP, CA 95330 <br /> OWNER : SUPER STORE INDUSTRIES <br /> Pnte Health <br /> Program Description Amount <br /> Invoice# IN0286932---Date of Invoice: 1126/2017 11111111 N111 1111111111111111111111111111111 HINT 11111MIN11 1111111111111 11E <br /> 112612017 1895 CaIARP FAC STATE SURCHARGE FEE $ 270.00 <br /> 1/26/2017 1921 HMBP-Regular-Primary Location $ 554.00 <br /> 112612017 1922 CERS Processing Fee $ 25.00 <br /> 1/2612017 2227 GEN 5<25 TONS PERMIT $ 1,772.00 <br /> 1/26/2017 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/2612017 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1126/2017 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1126/2017 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/26/2017 2360 UST-PER TANK FEE $ 139.00 <br /> 1126/2017 2360 UST-PER TANK FEE $ 139.00 <br /> 1/2612017 2360 UST-PER TANK FEE $ 139.00 <br /> 1126/2017 2360 UST-PER TANK FEE $ 139.00 <br /> 1126/2017 2361 UST FACILITY $ 583.00 <br /> 1/2612017 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 35.00 <br /> 1/2612017 APSA APSA SURCHARGE $ 26.00 <br /> Total for this Invoice $ 3,881.00 <br /> Payment Due Date 2/25/2017 <br /> TOTAL DUE this Billing Period $ 3,881.00 <br /> PAYMENT <br /> RECEIVED <br /> FEB 10 2017 <br /> EW4R0N MENTAL <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 HMBP 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.rpi <br />