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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE: Aril 14 1992 <br /> DEPARTMENT. PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH <br /> REASONIS)FOR THE REFUND: PAID TWICE FOR 1992 UNDERGROUND STORAGE TANK PERMIT. ON FEBRUARY 12 1992 <br /> FROM WALT ORR OWNER CHECK #1363 AND AGAIN ON FEBRUARY 16 1992 CHECK 0653639 FROM UNOCAL. <br /> UNION OIL SS#5421 <br /> 73 <br /> UNION <br /> lee <br /> RECEIPT # OTHER IDENTIFICATION # <br /> DEPOSIT PERMIT # DATE OF DEPOSIT PERMIT: <br /> AMOUNT OF REFUND: <br /> REFUND PAYABLE TO: &A i t'4Fl <br /> ADDRESS: C/o ENVIRONMENTAL HEALTH <br /> 445 N SAN JOAQUIN <br /> DEPARTMENT APPROVAL <br /> { Authorized Signature <br /> EXPENDITURES AUTHORIZED BY: <br /> Authorized Slpnature Date <br /> Claim examined and <br /> approved pursuant to Govt <br /> Coda Sac.29741 <br /> ADRIAN J VAN HOUTEN <br /> County Auditor <br /> by <br /> ENTITY NO FUND DEPT NO EXP CODE AMOUNT VENDOR NO <br />