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CASH OR CHECK REQUEST <br /> NCO-4871 DAL(11 83) <br /> PAY TO: San Joaquin Local Health D,.strict <br /> NEW VENDOR/PAYEE TAX IDENTIFICATION NUMBER <br /> Environmental Health Permtr erV ce: <br /> ADDRESS: P.O. Bl' X 2009 <br /> r Stockton, . 95201 EMPLOYER ID NO. <br /> CA � 9 <br /> I _ OR <br /> SOCIAL SECURITY 2 <br /> DIVER TO: � NUMBER <br /> (AUliiORIZATION <br /> REQUIRED) <br /> EEBLE YES NOWRITTEN <br /> • <br /> L � � - DOLLARS V <br /> to�� �J C AMOUNT CENTS <br /> REQUESTED BY EXT DEPARTMENT (CO-197 DISBURSEMENT APPROVAL) AUFH FOR CHECK DELIVERY RECEIVED CASH AMOUNT DATE <br /> Operations <br /> J. Lacy 4Richmond <br /> REQUEST <br /> VENDORIPAYEE REQUEST NUMBER f a 0 Q <br /> SUBMIT- DATE PAYMENT DUE �j i y w O AMOUNT TO BE PAID <br /> TR TING <br /> ID NUMBER <br /> ADD <br /> UNIT il:'=MO DAY YR MO DAY YR <br /> 1-2 12 13 22 23-25 26 - —37 38 41 - <br /> :;:::;: 57 59 6t 63 65 67 ;;;.;.. i 82 3 84 85 6 708— -------------- --- 120 <br /> ao 000 3i(o2� 16 R E []rl G995048 95 « ' 1� n i I u ;00 <br /> 1 7 <> <br /> PREPAID ITEMS 109911042 DATA �PAYABLES USE ONLY <br /> ANK <br /> w TR CODE CHECK NUMBER DATE �CAT.j STATE AMOUNTFOR <br /> CNTRYREPORTING <br /> MO DAY YR <br /> Z <br /> w1-2 .48 9 54 55 7 9 "s 71 72 74-76 77 87 <br /> Y <br /> a 43 I L� <br /> I <br /> f <br /> faMESSAGE:ENTER PRE-CODED MESSAGE CODE IN COL.45.47,AND/OR ENTER FREE FORM MESSAGE IN COL.48.120. <br /> TR <br /> CODE LINE 1 -- I LINE 2 <br /> L45 <br /> :E: 547 49 — — — --- -- 92'93 120 <br /> 1287 emit <br /> �s-9m OTHER ACCOUNT DISTRIBUTION <br /> ACCT. FDNC. LOCATION <br /> Z TR ¢� w CODE SUB' ETC. AMOUNT �_ <br /> 0 rnrn ¢ ACCT. 5 6 7 8 9 10 11 12 13 �� <br /> F <br /> Co 1-242, i� 2 44.45--48 951 2 56r5759 61 63 65 67 69 71 73 75 92 102 112 113 <br /> 0 <br /> I I I <br /> PAYEE COPY <br />