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jmwuIIV %'UUIV I T <br /> L )NMENTAL HEALTH DEPARTMF"T Pag <br /> 1 : WEBER AVE -3RD FLOOR <br /> SIOCKTON, CA 95202 COPY <br /> Phone: (209) 468-3420 <br /> IN CjE Account ID AR0003443 <br /> Facility ID FA0003855 <br /> PLEASE h';;IL <br /> PERMIT TO Date Printed 1/30/2006 <br /> BILLING ADDRESS - <br /> RE : USA GASOLINE#3696* <br /> USA PETROLEUM CO 2448 W KETTLEMAN LN <br /> 905 RANCHO CONEJO BLVD LODI, CA 95240 <br /> NEWBURY PARK, CA 91320-1716 <br /> OWNER : USA PETROLEUM CO <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0143400---Date of Invoice: 1/27/2006 11111 11111 IVI IN 111111 11111 1111 IN <br /> 1/27/2006 2220 SM HW GEN<5 TONS/YR $ 200.00 <br /> 1/27/2006 2244 2006 HAZMAT FEE $ 270.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2360 ADDITIONAL UST $ 125.00 <br /> 1/27/2006 2360 ADDITIONAL UST $ 125.00 <br /> 1/27/2006 2362 UST FACILITY& 1 TANK $ 500.00 <br /> 1/27/2006 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> Total for this Invoice $ 1,289.00 <br /> Payment Due Date 3/1 <br /> TOTAL DUE this Billing Period $ 1 289.0 <br /> PAYMEN-f <br /> RECEIVED <br /> F C B 13 2006 <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 OES/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.rpt <br />