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SAN JOAQUIN COUNTY <br /> ENVIM)NMENTAL HEALTH DEPARTMEI Page 1 <br /> 304 E WEBER AVE -3RD FLOOR <br /> SfOCKTON, CA 95202 <br /> Phone: (209) 468-3420 <br /> INVOICE Account ID AR0003361 <br /> Facility IDFAI 0002324 <br /> Date Printed 1/30/2006 <br /> MARIGOLD SHELL RE : MARIGOLD SHELL <br /> 6131 PACIFIC AVE 6131 PACIFIC AVE <br /> STOCKTON, CA 95207 STOCKTON, CA 95207 <br /> OWNER : TRAN, HUNG THANH <br /> Date Health <br /> Program Description <br /> Amount <br /> Invoice# IN0143461 ---Date of Invoice : 1/27/2006 I(IIIIII IIIIII III VIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIIIII VIII IIII IIII <br /> 1/27/2006 2220 SM HW GEN <5 TONS/YR S 200.00 <br /> 1/27/2006 2244 2006 HAZMAT FEE $ 85.00 <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 S 24.00 <br /> Total for this Invoice $ 1,104.00 <br /> Payment Due Date 3/1/2006 <br /> TOTAL DUE this Billing Period $ / 1,104.00 <br /> �OAYNjEj 4T-'� <br /> FEB 1 a <br /> S ENO QUIN—:(D r <br /> HEALTH DFPATtrtt,,.- , <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 /> i254.rpt <br /> -- ❑2.6UARAN-I FE ❑5.UTTER OFCREDtt LIa_3rrLTZ-r"vvac��� <br /> W3.INSURANCE El 6.EXEMPTION [:39.STATE FUND&CD <br /> VY TV0AT 7vn,rTTT4'A-PT(11\T ANTI fATIT1V� ATTTnTCC <br /> Check one box to indicate which address snou7m be used for legal notifications and mailing. <br /> Legal notifications and nrailiu is:'i t b-:sent to the tank owner unless bo.t 1 or 2 is checked. 1.FACILITY ❑2. PROPERTY OWNER ❑3. TANK U\hNL-R <br /> VH.APPLICANT SIGNATITRE <br /> Certification I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN F APPLICAN"f DATE -4 P ONE °=.' <br /> A l� > TITLE OF APPLICANT <br /> NAIAE OF tU 1 LICAN Plprim) a'6 <br /> e7MV,67 I/ <br /> STATE UST FACILITY NUMBER(Agency use only) 4'--$ 1993 UPGRADE CERTIFICATE NUNIBER(Agcncyuse only) 4= P <br /> Ll PCF Hwfwrc-a(1/99)-1/2 http://Nww.unidocs.org Rev.02/16/01 <br />