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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE _ 10/21/91 <br /> DEPARTMENT: _ Public Health Services/Environmental Health <br /> REASON (S) FOR THE REFUND: <br /> Double Payment for Underground Tank Fees <br /> Paid Check #4588 received August 16, 1989 and tank was <br /> removed In 1990. <br /> Gogna Ranch <br /> Camp # GOGNAI3 <br /> RECEIPT It OTHER IDENTIFICATION b � <br /> DEPOSIT PERMIT M DATE OF DEPOSIT PERMIT: _ <br /> AMOUNT OF REFUND: $ 150.00 <br /> REFUND PAYABLE TO: Gogna Ranch <br /> ADDRESS: %Environmental Health <br /> DEPARTMENT APPROVAL <br /> —Authoriz6d Signature <br /> 11 <br /> I <br /> EXPENDITURES AUTHORIZED BY: <br /> Authorized Signature Dale <br /> ENTITY NO. FUND DEPT. No. EXP. CODE AMOUNT VENDOR NO. Claim examined and <br /> approved pursuant to Govt. <br /> I Code Sec. 29741. <br /> PAUL G. HEURLIN <br /> County Auditor <br /> by <br /> Deputy <br /> Aud Coni 2e(Sn9) <br /> 1 <br />