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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE: April 17. 1992 <br /> DEPARTMENT: PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH <br /> REASON(S)FOR THE REFUND: OVER PAYMENT OF 9100 MADE ON JANUARY 31, 1989. CHECK #824682 FOR <br /> UNDERGROUND STORAGE TANK FEES. <br /> 1700 E YOSEMITE MANTECA <br /> UNION 17 <br /> RECEIPT # OTHER IDENTIFICATION 9 <br /> DEPOSIT PERMIT# DATE OF DEPOSIT PERMIT: <br /> t—'..r, <br /> ols <br /> REFUF�1����E Tl3t_UNt�CAL.' <br /> ADDRESS: C/O SNVISONMSNTAL HEALTH <br /> 445 N SAN JOAQUIN <br /> DEPARTMENT APPROVAL <br /> Authoriz Signature <br /> EXPENDITURES AUTHORIZED BY: <br /> AgAfi�'" 16,66- WOO - 6140 Authorized Signature Date <br /> 7 ` Claims examined and <br /> approved pursuant to Govt <br /> 4 <br /> Code Sec. 29741 <br /> ADRIAN J VAN HOUTEN <br /> County Auditor <br /> by <br /> Deputy <br /> ENTITY NO FUND DEPT NO EXP CODE AMOUNT VENDOR NO <br /> r , .,"7 <br /> 0, <br /> Aud-cont-2616/791 �' <br />