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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM& • Page 1 <br /> 1868 E HAZELTON AVENUE <br /> STOCK'r.DN, CA 95205 <br /> Phone: (209) 468-3420 <br /> INVOICE Account to r AR0037123� <br /> A:0:Facility ID 20706A•—j <br /> Date Printed ,._5/13/201 <br /> ULMER, KEVIN RE : MAXUM PETROLEUM /GENERAL <br /> "`*� <br /> MAXUM PETROLEUM / GENERAL PETR PETROLEUM <br /> <br /> STOCKTON, CA 95206 <br /> OWNER : MAXUM PETROLEUM / GENERAL PETR <br /> ( � I <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0238219---Date of Invoice: 2/1/2013 IIIIIIII IIIIII III IIIII IIIII IIIII IIIIIIIII IAVIIVIIVIIIIIIIIIV IIIIIIII <br /> 2/1/2013 1921 HMBP-Regular-Primary Location $ 255.00 <br /> 2/1/2013 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 35.00 <br /> 2/1/2013 2832 AST FAC 10 K-</=100 K GAL CUMULATIVE $ 675.00 <br /> 4/15/2013 9987 Haz Mat Program Penalty Fee $ 25.50 <br /> 4/15/2013 9994 PERMIT FEE PENALTY $ 675.00 <br /> 5/15/2013 9992 CORRECTION TO A PENALTY ($ 675.00) <br /> Total forthis Invoice $ 990.50 <br /> PAST DUE <br /> TOTAL DUE this Billing Period $ 990.50 <br /> 3 2 PAYMENT <br /> RECEIVED <br /> f" I <br /> / MAY 11 3 2013 <br /> { ^ 1 3p RO 'MENTA <br /> ,I/(�li �ALTH OEPARTMEN7 <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 thereafter <br /> 5254.rpt <br />