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SAN JOAQUIN COUNTY <br />,XNVIIR:ONMENTAL HEALTH DEPARTMENT <br />1868 E HAZELTON AVENUE <br />STOCKTON, CA 95205 <br />Phone: (209) 468-3420 <br />INVOICE <br />TOM VAN DE POL <br />VAN DE POL ENTERPRISES <br />PO BOX 1107 <br />STOCKTON, CA 95201-1107 <br />Page 1 <br />RECEIVED <br />FEB 17 2016 Account ID AR0003511 <br />ENVIRONMENTAL Facility ID FA0003919 <br />HEW TN nl7P4RTMFNT <br />Date Printed 2/2/2016 <br />RE: VAN DE POL ENTERPRISES <br />5491 F ST <br />BANTA, CA 95304 <br />OWNER: VAN DE POL ENTERPRISES <br />Date Health <br />i Prcgra n Description Amount <br />Invoice # IN0274018 --- Date of Invoice : 2/2/2016 <br />2/2/2016 1921 HMBP-Regular-Primary Location <br />2/2/2016 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE <br />2/2/2016 2832 AST FAC 10 K - </=100 K GAL CUMULATIVE <br />2/2/2016 APSA APSA SURCHARGE <br />j�-R 12l 1// s� <br />111111111111111111111 VIII ILII VIII VIII VIII VIII VIII VIII <br />VIII <br />$ <br />IIII 111111 VIII 1111 IIII <br />270.00 <br />$ <br />35.00 <br />$ <br />675.00 <br />$ <br />26.00 <br />Totalfor Invoice <br />$ <br />1,006.00 <br />Payment Due Date <br />3/3/2016 <br />$ <br />1,006.00 <br />TOTAL DUE this Billing Period <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 HMBP 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 thereaftei <br />5254.rpt <br />