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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMr''T Page 1 <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209) 468-3420 <br /> INVOICE Account ID AR0003320 <br /> Facility ID FA0003741 <br /> Date Printed 3/23/2004 <br /> BROADBASE INC dba JIFFY LUBE RE : JIFFY LUBE #598 <br /> JIFFY LUBE#598 1130 N MAIN ST <br /> 730 S BECKMAN RD STE B MANTECA, CA 95336 <br /> LODI, CA 95240 <br /> OWNER : FOWLER, DON W <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0115801 ---Date of Invoice: 2/4/2004 <br /> 2/4/2004 2220 SM HW GEN<5 TONS/YR $ 200.00 <br /> 2/4/2004 2244 2004 HAZMAT FEE $ 300.00 <br /> 2/4/2004 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total for this Invoice $ 524.00 <br /> Payment Due Date 3/6/2004 <br /> TOTAL DUE this Billing Period $ 524.00 <br /> ED <br /> MAR 2 3 2004 <br /> bqN j0A,,)IN <br /> H�ITV I RONMECOV N7y <br /> H DEPgRL <br /> A <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 /> 5255.rpt <br />