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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE: April 15, 1992 <br /> DEPARTMENT: PUBLIC HEALTH SERVICES/ENVIRONMENrAL HEALTH <br /> REASONS)FOR THE REFUND: PAID $356 (AUGUST 24, 1989 CHECK #2302 8150 AND OCTOBER 5 1989 CHECK <br /> X12537 FOR 8206) FOR UNDERGROUND STORAGE TANK FEES AND SURCHARGE FEE THESE ARE FARM TANKS AND <br /> EXEMPT FROM ALL FEES. <br /> ---___ r_— —„_.-.....,?D-Q2 j --BURY RD MANTECA <br /> JONES21 <br /> RECEIPT a OTHER IDENTIFICATION A <br /> DEPOSIT PERMIT A DATE OF DEPOSIT PERMIT: <br /> AMOUNT OF REFUND: S tris <br /> REFUND PAYABLE TO:__ (T,t,1� TD �G <br /> ADDRESS: C/O ENVIRONMENTAL HEALTH <br /> 445 N SAN JOAQUIN <br /> DEPARTMENT APPRO AL "L <br /> Y A thorized Signature <br /> EXPENDITURES AUTHORIZED BY: <br /> fAuthorized Signature Date <br /> /l 7� ClA �^ /' j(/1//� c rl Clnim examined and <br /> (I 4411 C C / /l J approved pursuant to Govt <br /> �(�l �(� /,l'J (WV Code Sea29741 <br /> (! / ADRIAN J VAN HOUTEN <br /> County Auditor <br /> by <br /> ENTITY NO FUND DEPT NO EXP CODE AMOUNT VENDOR NO <br /> And Cont eels/7fn P)f <br />