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SAN JOAQUIN COUNTY <br /> ENVIRO�WENTAL HEALTH DEPARTME Page 1 <br /> 304 &WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209)468-3420 <br /> unt ID AR00 00539 <br /> Facility ID FA0000540 <br /> LMMMUMMEMMMMM <br /> Date Printed 1/26/2007 <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# IN0157256—Date of Invoice: 1/2512007 IIIIIIIIIIIIIIIVIIIIIIIIIIIIVIIVIIIIIIIIIII VIIIVIII VIIIIIIIIIIIIIVIII IIII IIII <br /> 1/25/2007 2220 SM HW GEN <5 TONS/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 /> 1/25/2007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/25/2007 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/25/2007 2360 ADDITIONAL UST $ 125.00 <br /> 1/25/2007 2360 ADDITIONAL UST $ 125.00 <br /> 1/25/2007 2362 UST FACILITY&1 TANK $ 500.00 <br /> 1/25/2007 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> Total for this Invoice $ 1,310.00 <br /> Payment Due Date 2/25/2007 <br /> i����,II/n► �/ I y TOTAL DUE this Billing Period ,310.00 <br /> !�r16� ! �YPl9Yl. PAYMENT <br /> RECEIVED <br /> rZ'"WFO 2007 <br /> 'O V 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 /> i254 rpt <br />