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COUNTY OF SAN JOAQUIN <br />REFUND REQUEST FORM <br />()AIF October 21, 1991 <br />DEPAFITMENT: ______Public Health Services/Environmental HEal th <br />nEASON (S) FOn THE REFUND: <br />...._ ___ Fees_p-a.Lici_fqr Uflderground Tank instal lati,n which ha3 been cancelled _ <br />tern Meter for tank installation at 701 E Charter Wav <br />_------Pald--- n_Apr_i.t_23, U9j with check #11424 <br />nECEIPT N _ OTHER IDENTIFICATION N <br />DEPOSIT PERMIT N _ DATE OF DEPOSIT PERMIT: <br />AMOUNT OF REFUND: $ $226.00 <br />nEFUND PAYABLE TO: Western Meter <br />ADDREss: %Enyi ronmental Health <br />DEPARTMENT APPROVAL <br />EXr'ENDITURES AUTIIORIZED BY: <br />ENTITY NO <br />Authorized <br />ure <br />Authorized Signature <br />FUND <br />DEPT. NO. <br />EXP. CODE <br />AMOUNT <br />VENDOR NO. <br />I <br />Date <br />Claim examined and <br />approved pursuant to Govt. <br />Code Sec. 29741. <br />PAUL G. HEUFiLIN <br />County Auditor <br />jGl L1 C� ���C)G)� - ���(�`� r7v by <br />�/ �f Z + C> � . r' (J �UJ �i� •'/ � � G� <br />Deputy <br />A „t c-d za Is roI <br />