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SAN.JOAQUIN COUNTY I* 0 Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E MAIN STREET <br /> STOCKTON, CA 95202 <br /> Phone: (209)468-3420 <br /> INVOICE Account ID AR0001704 <br /> Facility ID FA0001705 <br /> Date Printed 1 1/31/2011 <br /> LICENSING RE : COSTCO WHOLESALE#38 <br /> COSTCO WHOLESALE#38 M LCENSINB 1616 E HAMMER LN <br /> 99 ~ P.O.Box 35005 1EATTLE.WA9812440 STOCKTON, CA 95210 <br /> ISS AH, A 98027 <br /> OWNER : COSTCO WHOLESALE CORPORATION <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0211319—Date of Invoice: 1/31/2011 IIIIIIIIIIVIIVIIIVIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIVIIIIIIII <br /> 1/28/2011 2220 SM HW GEN <5 TONS/YR $ 213.00 <br /> 1/28/2011 2244 2011 HAZMAT FEE $ 675.00 <br /> 1/28/2011 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/28/2011 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/28/2011 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/28/2011 2370 ADDITIONAL UST- 1702 COMPLIANT $ 125.00 <br /> 1/28/2011 2370 ADDITIONAL UST- 1702 COMPLIANT $ 125.00 <br /> 1/28/2011 2372 UST FACILITY& 1 TANK- 1702 COMPLIANT $ 550.00 <br /> 1/28/2011 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> 1/28/2011 ERSC ELECTRONIC REPORTING SURCHARGE $ 25.00 <br /> Total for lhls Invoice $ 1,782.00 <br /> Payment Due Date 3/212011 <br /> TOTAL DUE this Billing Period1,782.00 <br /> PAY FJ1r ?:i <br /> RECE'V`^ ) <br /> FEB 2 2 2011 <br /> ,DtiurrrA <br /> PEALTLrN or-a>Rnse'n <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 /> 5254.rpt <br />