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SAN JOAQUIN COUNTY Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTME9 • <br /> 304 E WEBER AVE -3RD FLOOR <br /> STOCKTON, CA 95202 ' <br /> Phone: (209)468-3420 �CI��V�p <br /> �® <br /> INVOICE WW ��CC V AccountlD AR0003402 <br /> FEB - 3 2005 <br /> Facility ID FA0003815 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES Date Printed 1/24/2005 <br /> USA GASOLINE#65 RE : USA GASOLINE#65 <br /> 30101 AGOURA CT#200 2500 W LODI AVE <br /> AGOURA HILLS, CA 91301 LODI, CA 95240 <br /> OWNER : KRISTMONT WEST, INC <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0128490---Date of Invoice: 1/24/2005 IIIIIIIIVIIVIIVIIVIVIIIIIIIIIIVIIVIIVII IIIIII VIIIIIIIIIII <br /> 1/24/2005 2220 SM HW GEN <5 TONS/YR $ 200.00 <br /> 1/24/2005 2244 2005 HAZMAT FEE $ 100.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2301 UST STATE SURCHARGE $ 15.00 <br /> 1/24/2005 2360 ADDITIONAL UST $ 125.00 <br /> 1/24/2005 2360 ADDITIONAL UST $ 125.00 <br /> 1/24/2005 2360 ADDITIONAL UST $ ,125.00 <br /> 1/24/2005 2362 UST FACILITY&1 TANK $ 500.00 <br /> 1/24/2005 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total for this Invoice $ 1,259.00 <br /> Payment Due Date 212312005 <br /> TOTAL DUE this Billing Period $ 1,259.00 <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 /> ilii rpt <br />