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PUBLIHEALTH SEVICES <br /> ,opo <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION _ Z< <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 c°�i' bw P <br /> 209/468-3420 <br /> REFERRAL FOR COLLECTIONS <br /> March 27, 1995 <br /> SITE NAME: <br /> ADDRESS: <br /> CITY: ZIP: <br /> APN: <br /> FACILITY ID: <br /> PRINCIPALS: <br /> PROPERTY OWNER: <br /> NAME: <br /> ADDRESS: <br /> CITY: <br /> PHONE: <br /> BUSINESS OWNER: <br /> NAME: <br /> ADDRESS: <br /> CITY: <br /> PHONE: <br /> OTHER CONTACTS OR RESPONSIBLE PARTIES: <br /> BRIEF EXPLANATION OF CLAIM: <br /> CHRONOLOGY OF EVENTS: (related to billing) <br /> 1 <br /> 1 <br /> A Division of San Aoaquia County Health Care Services <br />