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K%IC HEALTH SERVICE ,N JOA(TUIN CIMTY <br /> 1601 E. Hazelton Ave., P.O. Box 2009 <br /> - ! St ck°t n, CA 95201 <br /> ` - (209) 463-3425 <br /> Jogi KT;anrw, N.G., Health Officer pA ENS <br /> � REC NE <br /> JACKP40 �^ <br /> JACKPgT <br /> TIME OIL COMPANY r <br /> 401 S. CH RCKIE4LANE SANCNY,`�,.s�ERi y;S:v� <br /> 1? 50 N4. <br /> Billing 'Statement For 11990 Permit, Underground Tank Facility. <br /> Statement Date January 2, 19311 <br /> ,''me,ent�Gue t'efe��Fl•!TUary i, 7�T r_. _.. ._-.__-_. -. <br /> Facility Fee: lUO.tKi <br /> Container Numoer, W)l 50.00 <br /> 0002 50.00 <br /> 0003 50.00 <br /> TOTAL FEES DUE $250.00 <br /> NOTES: q <br /> 7 <br /> Notify Public Health Services, <br /> San Joaquin County of any <br /> corrections or changes <br /> necessary.- Your permit will <br /> be mailed upon receipt of <br /> payment and approval of <br /> facility. <br /> Return payment along with one <br /> COPY of this statement to: <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COMITY � <br /> ENVIRtONMENTAL HEALTH PERNITlSERVIMS <br /> P.0. BOX 2001 <br /> STOCK,TON, CA 35201 <br /> Penalties will be added after <br /> clue date as shown: <br /> .110 day&?IOU 9f..base.FK—_ <br />