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SAN JOAQUIN COUNTY Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209) 468-3420 <br /> INVOICE AccountlD AR0003410 <br /> PLEASE MAIL <br /> Facility ID FA000 0048 <br /> PERMIT TO <br /> BILLING ADDRESS <br /> Date Printed 1/24/2005 <br /> USA GASOLINE #835 RE : USA GASOLINE#835 <br /> <br /> STOCKTON, CA 95204 <br /> trtl�t .a OWNER : <br /> '� 7Amounit "' <br /> Health <br /> ,are Program Uescriptio'' <br /> Invoice# I140128678--Date of invoice: 1/2412005 (IIII I III I IIIV I VIII VIIIIIIIII II VIII VII VIII IIIIIIIIII IIII IIIIII(IIII IIIIII <br /> 1/24/2005 2220 SM HW GEN <5 TONS/YR $ 200.00 <br /> 1/24/2005 2244 2005 HAZMAT FEE - $ 100.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2360 ADDITIONAL UST $ 125.00 <br /> 1/24/2005 2360 ADDITIONAL UST $ 125.00 <br /> 1/24/2005 2362 UST FACILITY 8 1 TANK $ 500.00 <br /> 1/24/2005 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total for this Invoice 1,119.0 <br /> Payment Due Date 212 5 <br /> TOTAL DUE this Billing Period $ 1,119.00 <br /> PAYMENT <br /> RECEIVED <br /> FEB 2 2 2005 <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 /> tatieswill be added to all Permit Fees For DES I HMMP Fees For all SERVICE FEES <br /> 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 /> -'5S.rpt <br />