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S'tockton. CA 9S201 <br /> .ogil Kha ICY r M.D., Health O9 f1F •s.` <br /> H A,rr j�= <br /> <br /> <br /> I IENI UE <br /> Bi 11il3 St.at•F1men Firr 19941 Per.Tfti? , U ndrul'gE`Frund a-€IK Fir--c113?•Y . <br /> '-tateme-lit Date -.1p;-viluary 10, <br /> i"'_.yffient• D€.,fie ,.);ate i"4~Lrl'ua;'Y 10, 19"32, <br /> 1..F�,f�r'�a i€le. .fee 1„!:!S_�1 1 f�-°.00 <br /> - -r <br /> f Of-1 1731.4!4 <br /> 00021 171 ).0 1 <br /> '•_1aR+tp1•c alt I" !ee [iZ}3i 171 ti_'•0el <br /> Oct <br /> State e sL•3i'L`r'IargeW 0004 err.._0 <br /> t-4c)'Llify Public Health Services, Container fee 0004 ti's,;!,(g) <br /> ='till Joaquin County of --ny <br /> correcticons or changes <br /> ti e . ` : tis 's �. :i <br /> � = <br /> be mai el.J upoTl recei=pt-est --`-d� <br /> facility . <br /> Return payment.ent. c l crig wi I i+itt' <br /> copy Of this st-at-eme it to; <br /> PUBLIC'r. + V I <br /> r'ena1*ies will be added of ,e€- <br /> _ date <br /> _t - 1 <br /> '�LtC rJt`i 1.h•` %i`2 shown i <br /> 30 days - 100 of cu=e Fe.. <br />