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COUNTY OF SAN JOAQUIN <br /> REFUND REQUEST FORM <br /> DATE: September 13 1993 <br /> DEPARTMENT: PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH <br /> I <br /> REASON(S)FOR THE REFUND: OVER PAYMENT OF $1,192. OCTOBER 10 1992 CHECK #91021 FOR BACK FEES ON <br /> UNDERGROUND STORAGE TANK FEES AND SURCHARGE FEE WHEN OTHER TANKS WERE REMOVIED IIWAS DISCOVERED <br /> THAT TANK #14 WAS REMOVED IN 1979 <br /> i <br /> 2901 WEST LANE STOCKTON <br /> I <br /> FACILITY #003666 -— <br /> RECEIPT 9 OTHER IDENTIFICATION # <br /> DEPOSIT PERMIT / DATE OF DEPOSIT PERMIT: <br /> AMOUNT OF REFUND: 11 1_,_192 ) <br /> REFUND PAYABLE TO: AMERICAN MOLDING <br /> ADDRESS: CIO ENVIRONMENTAL HEALTH <br /> I <br /> 446 N SAN JOAQUIN <br /> � I <br /> DEPARTMENT APPROyXL <br /> Autlxxixd uen.�u. <br /> EXPENOITLIREB AUTHORIZED BY: <br /> AulFerlx.e 9lpluty. Url. <br /> ABATE TO 1000-01 04100 - 6140 0006 <br /> Claims examined end <br /> approved pursuant to Govt <br /> Code Sec. 29741 <br /> ADRIAN J VAN HOUTEN <br /> x County Auditor <br /> by <br /> Deputy <br /> ENTITY NO FUND DEPT NO EXP CODE AMOUNT VENDOR NO <br /> rN t:ox916/IBI <br /> 1 <br />