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SAN :4:��;OU I N LOCAL HEALTH i~1I��I H s CIT <br /> 1601 E. Hazelton Ave. , f.0. Box 2009 <br /> (2093) 49383-342S <br /> i 1 -r 3 r ,--- i,.-• r ,,•'11 <br /> .e . C•. :�ii-�r��.•(il-Elilc�•�t �-�'r�`,ili�i�'�vt•-�_=� :_ '�•i-�r{ ��°-Ialz <br /> i 1 11Y}ea �t•esi•etifen,t• fca% 1'a : i Pe%m-1 t•, lInderg-f c,L4nd I tn' r C i a.1 I• <br /> 'St.at•eiiieiit. Dsat e1'2'9 <br /> f"'ciyiistl�i• ►}[ir !?it•f�° rL'}"iJ=;l"'p <br /> _'.+Cis:' <br /> 41ts(s:� 'is7 ('0 <br /> TOTAL FEES DUE $260.0() <br /> W-1Y a; <br /> Health Jist,,i.ct• of e}iy <br /> }tet e sszir•y . Y,_sur 1--`}"Mi F W 11 <br /> 1{sc;llti'�:i L4PIF'i} i•eztript- is"f <br /> payment and -:�PProvai of <br /> ri—�C111t•�y . <br /> copy of this st--tefftelrlt t-1--t! <br /> ssaslf1r Le_UC L H.-r�i._'sH' DI'ti,ERICf <br /> i ;J I1?} hli`I`�:' ti11 <br /> _ HEALTH ri=;fi1 I l i =fir l ICES <br /> W,.. OC."p- f dim' CA —4'n2 0 f <br /> �'el id.i i•I epi <br /> Will Lie -3&Jeff C,1 t•er <br />