Laserfiche WebLink
) jn jdWa(, Joint, Corporacion, � <br /> Partnership, firm or Agcncy <br /> ( m of Ban(./Flrwnclal Insti tun on and Lac* <br /> Claim No. <br /> PROOF OF CLAIM <br /> SSN/rax 10 a <br /> The trndarsiuned Doua Wilson <br /> (Naw of Person making the Claim) <br /> states that the Federal Deposit Insurance Corp rmt In LIquldation Is Ju <br /> (Name ofgank/Flnanclal institution) <br /> Indebted to San Joaquin County Environmental Health Division In the s. <br /> ***Nine hundred & two anjlUU/ lUUk/*jAcit/Corporation/Parcric"hlp/Flrm/Agoicy) <br /> dollars upon the ibtlowins claim: <br /> Account Typo Liability Number uninsured Principal I Liability Number Uainsured incerr <br /> D <br /> E <br /> P <br /> a <br /> s <br /> 1 <br /> T <br /> 6 <br /> Total P L I <br /> Descrlptlon of (Invoice) claim'. Liability Number Amount of claim <br /> C Invoice #005796 <br /> For: Back Fees due for Facility Fees, Tank Permit Fees, <br /> and Surcharae Fees for the property located at <br /> $ 935 E. Scotts, Stockton, CA rocai claim: $902.00 <br /> Undersigned further states that he/she makes this claim vn behalf of S. J. County-Environmental Health <br /> and that no pari of sofa debt has been paid, that S. J. County-Environmental Health <br /> (Individual/Joini/corporstlon/Partnershlp/Flrm/Aget y) <br /> has given no endorsement or assignment of the same or any part thereof and that there Is 0_o set-off or counterclaim, or ort <br /> Leval or "itabte defense to said claim or any cart thereof. <br /> NAME � ¢J REHS-Supervisor <br /> na <br /> (SI ture of Person suking the Claim) (Title) <br /> Environmental Health Division <br /> FIRM <br /> (If applicable) <br /> 304 E. Weber Avenue <br /> A00RESS <br /> CITY/STATE/21P Stockton, CA 95202 <br /> L 11t1,6ff a- �A/2"c_SOX) ulaA,l.CAMM <br /> Scorn [o and subscribed by bef re <br /> (Name a( Person Signing) �01111111"��e,a^.y�ft <br /> this Clw— day of yG/(�� 19-24 . �'IY COIIIIIL�itw A1L.� <br /> My Comm isslen Expires: y/.;27/.�OdO - <br /> (Signature of 01 icer Adainistering Oanh) <br />