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-Mry COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMF <br /> 304 E WEBER AVE -3RD FLOOR .► Page 1 <br /> STOCKTON, CA 95202 WWI <br /> Phone: (209) 468-3420 <br /> INVOICE Account ID AR0003501 <br /> Facility ID F FA0003911 <br /> Date Panted 2/5/2004 <br /> IMMUMOMMMOMENd <br /> TOM VAN DE POL RE : VAN DE POL ENTERPRISES INC <br /> VAN DE POL ENTERPRISES 816 E FRONTAGE RD <br /> PO BOX 1107 RIPON, CA 95366 <br /> STOCKTON, CA 95201 <br /> OWNER : VAN DE POL ENTERPRISES <br /> n„o Health <br /> Program Description <br /> Amount <br /> Invoice# IN0116357—Date of Invoice: 2/4/2004 <br /> 2/4/2004 2220 SM HW GEN<5 TONS/YR $ 200.00 <br /> 2/4/2004 2301 UST STATE SURCHARGE $ 15.00 <br /> 2/4/2004 2301 UST STATE SURCHARGE $ 15.00 <br /> 2/4/2004 2301 UST STATE SURCHARGE $ 15.00 <br /> 2/4/2004 2360 ADDITIONAL UST $ 12500 <br /> 2/4/2004 2360 ADDITIONAL UST $ 125.00 <br /> 2/4/2004 2362 UST FACILITY& 1 TANK $ 500.00 <br /> 2/4/2004 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total for this Invoice $ 1,019.00 <br /> Payment Due Date 3/6/2004 <br /> TOTAL DUE this Billing Period $ 1,019.00 <br /> PAYMENT <br /> RECEIVED <br /> FEB 2 3 2004 <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 /> Penalties will be added to all Permit Fees For DES/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 /> 5255 rpt <br />