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tNVIKONMENTAL HEALTH DEPARTMENT Page 1 <br /> 600 E MAIN STREET <br /> STOCKTON, CA 95202 <br /> Phone: (209)468-3420 '10 <br /> COPY <br /> INVOICE 4A 0� AccountlD r AR0016730 <br /> Facility ID FA0009730 <br /> Date Printed 3/31/2010 <br /> FAIRMONT REHABILITATION HOSPIT RE : FAIRMONT REHABILITATION HOSPITAL <br /> 950 S FAIRMONT AVE 950 S FAIRMONT AVE <br /> LODI, CA 95240 LODI, CA 95240 <br /> OWNER : LODI SKILLED NURSING SVC <br /> Date Health <br /> Program Description <br /> Amount <br /> Invoice# IN0198676---Date of invoice : 2/2/2010 IIIIIIIIIIIIIIIIIIIIAVIIIVIIIVIIIVIIIVIIIVIIIVIIIVIIIIIIIIIIIII1111111111111 <br /> 2/1/2010 2244 2010 HAZMAT FEE $ 255.00 <br /> 2/1/2010 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 2/1/2010 ERSC ELECTRONIC REPORTING SURCHARGE $ 25.00 <br /> 3/20/2010 9987 Haz Mat Program Penalty Fee $ 25.50 <br /> Totalforthislnvoice $ 329.50 <br /> Payment Due Date 3/4/2010 <br /> TOTAL DUE this Billing Period $ 329.50 <br /> PAST �� <br /> Delinquent charges <br /> will be forwarded to <br /> COLLECTIONS <br /> irr, 30 davgq <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 I 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.rpt <br />