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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPART Page 1 <br /> 304 E WEBER AVE - 3RD FLOOR <br /> STOCKTON, CA 95202 <br /> Phone: (209) 468-3420 <br /> INVOICE AccoantlD AR001706 <br /> Facility ID FA0010067 <br /> Date Printed 3/15/200 <br /> BROADBASE INC dba JIFFY LUBE RE : JIFFY LUBE #2497 <br /> JIFFY LUBE #2497 4715 N WEST LN <br /> 730 S BECKMAN RD STE B STOCKTON, CA 95210 <br /> LODI, CA 95240 <br /> OWNER : FOWLER, DON W <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0128184---Date of Invoice : 1/24/2005 1111111111111111111 IN <br /> 1/24/2005 2220 SM HW GEN<5 TONS/YR S 200.00 <br /> 1/24/2005 2244 2005 HAZMAT FEE $ 330.00 <br /> 1/24/2005 2399 UNIFIED PROGRAM FAC STATE SERVICE FEE $ 24.00 <br /> Total for this Invoicel $ 554.00 <br /> Payment Due Date 2/23/2005 <br /> TOTAL DUE this Billing Period $ 554.00 <br /> PAYMENT <br /> RECEIVED <br /> MAR 1 5 2005 <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 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 /> 52i5 T1 <br />