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PUBLIC—HEALTH SERVICES <br /> SAN JOAQUIN COUNTY �. <br /> ..o <br /> ENVIRONMENTAL HEALTH DIVISION a <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> REFERRAL FOR COLLECTIONS <br /> March 7 , 1995 <br /> SITE NAME: <br /> ADDRESS: >/O 6 <br /> CITY: Goo' ZIP: CjSli/� <br /> APN: 01401— 0 80- 6o - Ck <br /> FACILITY ID: o0 39�j` <br /> PRINCIPALS: <br /> PROPERTY OWNER: <br /> NAME: GARYPI- IFIAGL. <br /> ADDRESS: 3io N /J✓E - <br /> CITY: L-&p_ -ZA <br /> PHONE: <br /> BUSINESS OWNER: <br /> NAME: GOVoA %r�OiHf��otid <br /> ADDRESS: 3i0 AVE . <br /> CITY: GOA?' <br /> PHONE: (Zaq) 3(fJ-�f75 <br /> OTHER CONTACTS OR RESPONSIBLE PARTIES: <br /> BRIEF EXPLANATION OF CLAIM: <br /> CHRONOLOGY OF EVENTS: (related to billing) <br /> ��/!9/.y: vG% �✓scovE�Fi�J oY,�r�JG co,./Jr/4.,�7- IS�-'�10�-T.c� <br /> LG.rr.(G- <br /> a4c7e- 7-V <br /> 4 CrPY of $ioar�( STsJTB+En�%Fv� r�wZj QcB+ r vn�vEsP62o��(/� y9s�� <br /> � I <br /> r�c*5�i3/r/t�—��a?t�bpp'�,Earz.�vs aQE'cs�vwo 3/,r/coli 1 <br /> 3/�r Y3•, CeP4' or- U{&+L ,d 733tY >�. �! 116. cca RF �ErvE� �yrr/93c <br /> A Division of San Joaquin County Health Care Services <br />