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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE: April 15 1992 <br /> DEPARTMENT: PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH <br /> REASON(S)FOR THE REFUND: PAID ACTIVE FEES FOR UNDERGROUND STORAGE TANK. TANKS WERE REMOVED PRIOR TO BILLING <br /> DATE. PAID CHECK /2961 ON SEPTEMBER 6 1989. <br /> 18626 COPPEROPOLIS ROAD LINDEN <br /> RJSANIB <br /> RECEIPT I OTHER IDENTIFICATION A <br /> DEPOSIT PERMIT I DATE OF DEPOSIT PERMIT: <br /> AMOUNT 160 Agg � f <br /> 11EFLNb FAIAlilfiII"IM6ANNINUI <br /> ADDRESS: C/O ENVIRONMENTAL HEALTH <br /> 445 N SAN JOAQUIN <br /> DEPARTMENT APPROVAL <br /> i A Mrlted 6lyruture <br /> EXPENDITURES AUTHORFLED BY: <br /> Au1lwlzed ebn.Me p9ta <br /> A009 TO 1066101 ' 0400 • G 140 -- •); D <br /> Claims examined and <br /> approved pursuant to Govt <br /> Cade Sec. 29741 <br /> ADRIAN J VAN HOUTEN <br /> County Auditor <br /> by <br /> Deputy <br /> ENTITY NO FUND DEPT NO EXP CODE AMOUNT VENDOR NO <br /> i <br /> _ <br /> C <br /> /10PY <br /> i�d-Cent-2916/)91 ��j� �T� <br />