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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , P. 0. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 4w-6781 <br /> Jogi Khanna, M.D. , Health Officer <br /> . DAUSE23 <br /> BILL DAUSE BILL DAUSE <br /> P. 0. BOX 423 , 23597 N HWY 99 <br /> ACAMPO, CA 95220 ACAMPO, CA 95220 <br /> Billing statement for 1987 Permit Underground Tank Facility. <br /> y Statement Date: March 15, 1987 <br /> Due: April 15, 1987 <br /> Facility E 100 <br /> Container N `Status PAYMENT <br /> 1 A � RECEiV2D <br /> 2 A 50 <br /> 3 A 50 MND' 4 <br /> ENVIRONMENTAL HEALTH <br /> $ PERMIT)5ERVICES <br /> State surcharges @ $56 per tank x _ _ of <br /> Subtotal of permit fees: $250 <br /> Additional Billings or Credits <br /> S _ <br /> TOTAL FEES DUE: $ 251).,)0 <br /> Penalties will be added Notify the San Joaquin Local Health District <br /> after due date as shown: of any corrections or changes necessary. <br /> Permit will be mailed upon receipt of payment <br /> and approval of facility. <br /> 30 days - 100% of Base Fee Return payment along with one copy of this <br /> statement to: <br /> San Joaquin Local Health District <br /> * Environmental Health Permit/Services <br /> A - Active <br /> P. 0. Box 2009, Stockton, CA 95201 <br /> TC - Temporary Closure <br /> PC - Permanent Closure <br />