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.AW. . . <br /> APPENDIX C <br /> EMERGENCY, ABANDONED, RE'CALCITR.ANT (EAR) ACCOUNT <br /> REQUEST FOR PAYMENT FORM <br /> This form is to be filled out by requesting Regional Board. or Local <br /> Implementing Agency (LIA) at the time of payment requests . The <br /> Accounting Office requires three copies with original signatures. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Requesting Agency: ENVIRONMENTAL HEALTH DIVISION <br /> Site Name : MARLER INDUSTRIES <br /> Site Address : 75 E ALPINE AVE STOCKTON CA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Payee Name : ENVIRONMENTAL HEALTH DIVISION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Payee Address : ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388 <br /> STOCKTON CA 95201-0388 <br /> (Include information on a seoarace page if more than one payee. ) <br /> Total Amount of this Payment Request* $24, 962.10 <br /> Agency Contact Person: Name RON ROWE <br /> Title SR REGISTERED., ENVIRONMENTAL. <br /> Telephone-Number (209) 468-0342 <br /> Signature .. Date : 12/07/95 <br /> (Regional Board or LIA Project Manage ) <br /> * Attach invoices to support the total amount claimed on this request. <br /> A Vendor Data Record Form must be comoleced for each Payee. <br /> State Use Oniv: Approval for Pavment CALSTARS CODING: <br /> 0550-705-05 <br /> EAR Account Site Number: REGION: <br /> Total Funding Approved for this Project : $ <br /> Total Previously Paid: $ <br /> Total Approved for this Payment Recuest: $ <br /> Balance Remaining: $ <br /> Reviewed by (EAR Account Contract Manager) : Date : <br /> Approved by (Payment Authorization Signature) : Date : <br />