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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPART 'T Page 1 <br /> 600 E MAIN STREET <br /> STOCKTON, CA 95202 <br /> Phone: (209) <br /> Account ID AR0000539 <br /> Facility ID FA0000540 <br /> Date Printed4/4/2007 <br /> COUNTRYSIDE MINI MART RE : COUNTRYSIDE MINI MART <br /> 14971 N HWY 88 14971 N HWY 88 <br /> LODI, CA 95240 LODI, CA 95240 <br /> OWNER : BURGIN, GARY <br /> -- Date _ Health __ _ - <br /> Program Description Amount <br /> Invoice# IN0167256—Date of Invoice: 112512007 11111111 HIT 11111111 Hill1IIIIIIIII IIIIIIIIIIIIIIIIIIII IN111IIIIIIIIfill IN <br /> 1/25/1007 2220 SM HW GEN<STONS/YR $ 206.00 <br /> 1/25/2007 2244 2007 HAZMAT FEE $ 285.00 <br /> 1/25/2007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/2512007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/252007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1252D07 2360 ADDITIONAL UST $ 125.00 <br /> 1252007 2360 ADDITIONAL UST $ 125.00 <br /> 1252007 2362 UST FACILITY&1 TANK $ 500.00 <br /> 1252007 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 3/152007 9987 Haz Mat Program Penalty Fee $ 28.50 <br /> 4/42007 9999 PAYMENT ($ 1,310.00) <br /> Total forthls Involcel $ 28.50 <br /> p u�t �E Payment Due Date 212 7 <br /> jENAI TY OWING <br /> y�I G 11G TOTAL DUE thiPAYMET <br /> s Billing Period $ 28.50 <br /> RECE VED <br /> pPR 3 0 zoo, <br /> SAN JOAQUIN <br /> ENVIRONMENTAL TM <br /> HATH 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 I 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 />