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- iV <br /> �. LL <br /> ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , P. 0. Box ? }Q9 r <br /> Stockton, CA 95201 <br /> (209) 466-6781 'F <br /> Jogi Khanna, M.D. , Health OfficeVE . <br /> S""'"J 04, <br /> SAN JOAQUIN COUNTY -SAN JOAQUIN COUNTY-WILSON WAY COMPLE <br /> 222 E. WEBER AVENUE •444 S. WILSON WAY <br /> STOCKTON, CA 95202 • STOCKTON, CA 95205 <br /> Billing statement for 19$7 Permit Underground Tank Facility. <br /> Statement Date: SEPTEMBER 3 1987 <br /> Due: OCTOBER 3, 19137 <br /> Facility $ 100 <br /> Container # *Status 50 <br /> 1 A $ ___ — <br /> __z_ T_ PAYMENT <br /> 3 77 1 50 RECEIVED <br /> SEP 2 5 187 <br /> ENVIRONMENTAL HEALTH <br /> State surcharges @ $56 per tank x PERMIT/SERVICES <br /> _ - <br /> Subtotal of permit fees: $400.00 <br /> Additional Billings or Credits <br /> (overpayment of 1986 fees) _ $ 30.00 <br /> TOTAL FEES DUE: $ 37 <br /> 0-00 <br /> Penalties will be added 'Notify the San Joaqui n Local Heal th L%� <br /> after due date as shown: of any corrections or changes necessary_ <br /> Permit will be mailed upon receipt ar <br /> and approval of facility. <br /> 30 days - 100% of Base Fee Return payment along with one copy 0`7 <br /> = <br /> statement to: <br /> San Joaquin Local Health District <br /> Environmental Health Permit/Services <br /> * P. 0. Box 2009, Stockton, CA 95201 <br /> A - Active <br /> TC - Temporary Closure <br /> PC - Permanent Closure <br />