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FUKJ r Tn ur,-ZK,jIr- JC }l1ltJ COUNTY - .. <br /> 445 N. Sari Joaqulr! atF*t WA MAfLINB <br /> P.C►. BOX A* <br /> atocktor}, CA 962011 <br /> (2(6) 46h-3421 <br /> Ju-li Khanna, M,D. {deal,b !if f icer <br /> R,vINCH MARKET RANC 23 <br /> 2*69 S 'SANTA FE RB RANCH MARKET <br /> RIVERBANK, jrA '-+5;�,' 2.'SSS -a' SAN A FE RD <br /> RIVERBANK, CA '36'1 <br /> Billing Stat rit For 19% 'r'e,°crit, Urluer�yrcernd ant; Facility. <br /> a er#ent Gate frit :3, l_�1 <br /> �siY#�i1t• d !Gy �a .�j <br /> 'Pi ti <br /> State Surcharge (.u)(11 %.00 <br /> Container tee )i 170.100 'r4KWO4,,- an -4/g t <br /> :state sI1rGfef. 1)(1(1 56.U() 00 QC-mVe <br /> 1 eE "000r.3 17 C'+.(9) 2 <br /> 6Xi6ed 6n th'i 5 <br /> :tate surc#-large 0003 •dam` LU <br /> fGTAL FEES DUE <br /> $678.0(1 V <br /> Not•ity F'iatrlii Healtt! aervii c�5 �[ s is, �rS <br /> San Joaquin? county 0any <br /> [cow-{t•llcr{s {cr' rtltlrl'?t--. <br /> neeessary. you'T. j�i i l <br /> uE r#ai]ei! Wrjn r'eCeif•t• Cit <br /> Payment and approval e;;1 <br /> facility. <br /> Return Payritent alcem with cine <br /> copy of tbis 5t.atemerlt- to: <br /> Pt?Bt % PiAL T H %WI CEt <br /> : J JI'LAsQq(fifV�`�C:(iUNTY �y ,may ! C <br /> EN IRl{I+{{HEAL HEA {;1 f EMI{1SERVi ES <br /> P.O. BOX 2(9)9 <br /> STOCKTON, CA 35200 <br /> I <br /> Penal ti es will to added ai t.er <br /> tk1G date as shr-An: <br /> 30 days - 000% of Base Fee <br /> i <br />