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PUBLIC HEALTH SERV1(:F`-'*SRN JGAWIN CL11M <br /> 16t�1 E. Ha elt-cfrsJI <br /> CA <br /> , P.O. Box FU <br /> Stockton, CA 9520,E <br /> (209) 468-3.25 <br /> Jrgi Khay?na, M,D., #L-alr.h Officer <br /> I=3}��#Ft17 <br /> E.R. CAWENTER Co., !Ne, E. R. CARPENTER CO., INC. <br /> P. C. vix 11,119 IM-Xa. <br /> LATHRF9, CA LA,THROP, CA 9K-3O <br /> Pilling StatEiftent For 1990 Pert:i t, Underground Tang; Facility. <br /> state+ent. Date . 'January 4, 1390 <br /> PaYment Due Date; February a, ls`'[) <br /> Facility Fee: 100.(yu <br /> Container NurA)er= 0001 SMC <br /> TOTAL FEES OUE <br /> NOTES; <br /> Notify Public Health ISE-rvice=, <br /> San JozvWin County of any <br /> corrections or charges <br /> necessary. Your permit will <br /> to r;.ailed wjr, receipt of <br /> paymEnt and apprml of <br /> facility. <br /> Return payment along with: one <br /> copy of tfds statement to; <br /> MELIC HEALTH SEMCES <br /> SAN ,IJAF,�VIN t.0 N Y <br /> EWIRWIDNTAL HEALTH PERMIT/SERVICES <br /> P.O. BOX 2W <br /> STOCKT&I, CA 9S201 <br /> Penalties will tie added after <br /> due date as shgon: <br /> 30 dd-y5 - 100% of Rase Fee <br /> i <br />