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PMC IfALTW , SM JOWIM C JN T Y <br /> 1601 E. Nazei e., P.OBox 200 <br /> Stri(ktcm, CA 9,01 <br /> !M) 468-3425 <br /> Iogi Khanna, i1-C!., Heap!, OfficEr <br /> '301 <br /> " Ty- <br /> y .,t�fs <br /> <br /> <br /> <br /> <br /> , <br /> 6�illi�rj 'St�.t.tMent. �:,1• it°:�� F°ertnii•, ;t��.;.�r��)U� (ari't: EaClli.�•? <br /> St•at.e ent Date l3rivapy 2, w`=fit <br /> Pament- Clue Oate; �Fc-brlje.`y i'a9' <br /> F�iciiity Fee; <br /> C.j,ntallier rN':mbEr 00M 'F4').ly; <br /> 00 <br /> l)+J!'� tl K.Cul <br /> =',-''Tk FEES DJE _-J :) �t) <br /> NOTES,. <br /> Notify Pljbll� healtrl Et`Viie ; <br /> ,an ka'gLin CtqJl "y of amv <br /> LC'i`retf•iGlt� �1' C}"fi:r�t: <br /> F-eriillt. will <br /> to maileld Upon re(eipt i) <br /> Paywent and approval, of <br /> facility. <br /> Return Payiife'n't along h!1 th one <br />'4 <br /> copy of 11-lis <br /> lwai <br />�f <br /> T <br /> Mil". HEALTH :3==fiVI '=S <br /> 14 _010111N' CGIV1ii Y <br /> tifipr ,. <br /> ��l aiii1'ME TF L HEALTH t tllri.i 1 u_11 L'� <br /> P.tt. BOXY 20019- <br /> STUt'1<:T ON, 4n )KO i <br /> Penalties will be ?LIUU af%tf' <br /> due da i.e a`• 5,ho m <br /> ") days - i 00- C f G;KSf F&e <br /> i <br />