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PUBLIC j` H SERVICES, SAN 30AWIN CONN11�� , <br /> 445 N. San Jnaquin Street Mllf A MAILING AOOhL'+�1 <br /> i <br /> P.O. Box 20019 <br /> Stotl:t'�i , CA `35241 <br /> 468--3427 <br /> Jogi Khania, M.U. , Health Officer <br /> 'y JA KP40 <br /> JACKPOT <br /> iME OIL COMPANY 441 S. CHEROKEE LANE <br /> <br /> <br /> II Eillii7g St.at.ernent. for 1991 Permit, Underyrou),d tank Facility : <br /> Statement. Oate January <br /> Payment Due Date: rebruar'y 7 , VJ91 <br /> i ). <br /> Container lee 0441 i,C C .0 <br /> State =urChdiyCIV 1 56.r a0 <br /> '� fl' 00,00'�:ontainer. fee 0002 <br /> State surcharge 0002 56.00 <br /> Gont.ainer fee 4443 114.44 <br /> State surcharge '00: 56.00 <br /> i -- <br /> � TOTflL rEtS DJE. 4678.04 <br /> I NUiES: <br /> f <br /> Notify Public HealtH 'cervices, <br /> San Joaquin County o'• any <br /> corrections of, changes <br /> f <br /> necessary . Your per:nit. 'Oil! <br /> I be mailed upon receipt of <br /> payment- and approval of <br /> facility <br /> Ret.urr, payment alcn3 with one <br /> copy of this statement. to: <br /> PUBLIC HEALTH SERVICE' <br /> SAN JOAQUIN COUNTY <br /> ENVIRCINME141AL HEAL`IH PERM!IISERVICES. <br /> p.o. Sol 2409 <br /> 31 DCF::i DN, <br /> CA ';52C%1 <br /> Penalties will be added after <br /> due date as shown: <br /> 30 days - 100% of lyase Fee <br /> I <br /> I <br /> I <br /> I <br /> f <br /> I <br />