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JAN,JUAWUIN I,UUN I T <br /> EN4RONMENTAL HEALTH DEPARTMF"T Page 1 <br /> 304 E WEBER AVE-3RD FLOOR <br /> STOCKTON, CA 95202 COPY <br /> Phone: (209)468-3420 <br /> IN CE Account ID AR0003180 <br /> (� Facility ID F FA0003602 <br /> PLEASE MAIL <br /> PER1,11T TO Date Printed 1/30/2006 <br /> Immmmmoommmmms <br /> �t cT"II I t/ C ,D/9Z ®II.I.IN x AODFiESS <br /> (h I N8 .., l/ RE : USA GASOLINE#3502' <br /> USA PETROLEUM CO 35 N CHEROKEE LN <br /> <br /> <br /> OWNER : USA PETROLEUM CO <br /> Date Health <br /> Program Description Amount <br /> Invoice# IN0143384—Date of Invoice: 112712006 <br /> IIIIIIIIIIIVIVIIVIIIVIIVIVIIIVIIVIIVIIVIII IIIIIIIVIIIIIIII <br /> 1/27/2006 2220 SM HVJ GEN<5 TONS/YR $ 200.00 <br /> 1/27/2006 2244 2006 HAZMAT FEE $ 270.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/27/2006 2360 ADDITIONAL UST $ 125.00 <br /> 1/27/2006 2360 ADDITIONAL UST $ 125.00 <br /> 1/27/2006 2362 UST FACILITY& 1 TANK $ 500.00 <br /> 1/27/2006 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 24.00 <br /> Total forthis Invoice $ 1,289.00 <br /> Payment Due Date /20 <br /> TOTAL DUE this Billing Period $ 1,289.0 <br /> PAYME <br /> RGCOV <br /> SAN JOAQUIN COUP' 1 <br /> HEALTH DEPARTMEf4T <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 />