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ENVIRONMENTAL HEALTH DIVISION <br /> �' ' <br /> ACCOUNTING WDRIKSHEET <br /> UNIT # 's - ---d <br /> V (�LL <br /> COLM?UTER/PE'R-MIT # 3t,305 <br /> SITUS/FACILITY ADDRESS: SI cf 57, < -4, S G-4 <br /> DBA: Vf� (1 c Cmc <br /> SILL TO: PHONE: <br /> BILLING ADDRESS: 1q 3 4= CA � 1 <br /> C[TY/STATE: T, e C/4 K a ZIP: <br /> PROGRAM: 1A. (,-r TYPE OF SERVICE: 0 V-e tc� <br /> THE MINIMUM TIME FOR EACH INSPECTION IS ONE (1) HOUR, ANY ADDITIONAL INSPEC'T'ION TIME IS COMPUTED TO THE <br /> NEAREST HALF (1/2) HOUR, INCLUDING TRAVEL TIME. <br /> DATE WEEKDAY WEEKNIGHT HOLIDAYS DESCRIPTI©Y OF `V{]R;7 REHS NAME <br /> of SAM- 4:30PM-SAM/ <br /> SERVICE 4:30PM WEEKENDS 1° t <br /> 44 r; <br /> �- !V <br /> -�1.�.Z(AMIti 4��• L 1 N Zu �X /1 1 � /02 <br /> f <br /> I <br /> TOTALS <br /> BALUNCE DUE: <br /> BILLING NATE: y � ' <br /> EH 23 074 (Rev 3/22/91) s <br />