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SAN JOA,.IUIN COUNTY <br /> ENYIROAMENTAL HEALTH DEPARTM' Page 1 <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKPhone: ON,209 46 95202 <br /> -3420 <br /> INVOICE Account ID AR0000539 <br /> LUMUMMMMMNMMNWA <br /> Facility ID FA0000540 <br /> LOMMMMOMMMMUMN <br /> Date Printed 1/30/2006 <br /> lommommmmmommawA <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# IN0143423—Date of Invoice: 1/27/2006 IIIIIIIIIIIIVIIVIIIVIIVIIIIIIIVIIIVIIIVIIIIIIIIIIIIIII IIII IIII <br /> 1/27/2006 2220 SM HW GEN <5 TONSNR $ 200.00 <br /> 1/27/2006 2244 2006 HAZMAT FEE $ 285.00 <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 Invoicel $ 1,304.00 <br /> Payment Due Date 3/1/2006 <br /> TOTAL DUE this Billing Period <br /> {{ $ 1,304.0 <br /> i '_a ♦. I <br /> R�"C <br /> i.�=iijr-r <br /> FEB 2 4 2006, <br /> SAN JCA-LUii i COUNPJ <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 CES/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.tpt <br />