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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 2` ? <br /> a: a <br /> JOGI KHANNA M.D.,M.P.H. a ' <br /> Health Officer r... <br /> 9� FORN� <br /> P 0. Box 2009 (1601 East Hazelton Avenue) • Stockton,California 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION - UNIT III <br /> BILLING STATEMENT <br /> (209) 468-3427 <br /> FACILITY ADDRESS: )rAn .�f" Qllll1 het C�CJO_' 174 1�1.Ih1Q�nur S WEEPS # <br /> BILL TO: -Thorpe ' 7 Lr?a <br /> BILLING ADDRESS: ? ( g O X )5 y (� <br /> / <br /> CITY/STATE: � )cl��c"`•/° C A ZIP: <br /> PROGRAM: V J_r BILLING DATE: <br /> THE MINIMUM TIME FOR EACH INSPECTION IS ONE (1) HOUR, ANY ADDITIONAL INSPECTION TIME IS COMPUTED TO THE <br /> N T 1/2) HO INCLUDING TRAVEL TIME. <br /> - r r 3 / <br /> DATE TOTAL WEEKDAY WEEKNIGHT CONSUL- DESCRIPTION REHS <br /> of HOURS 8AM-5PM 5PM-8AM/ TATION at of WORK SIGNATURE <br /> SERVICE WORKED $53.00/HR WEEKEND/ $53.00/1-iOUR <br /> HOLIDAYS <br /> $79.50/HR <br /> Zl R I 1 . O aw av t <br /> ?�r • � PM 3�fMPL0 . <br /> IS 3S[� QNP0nat 4ow tw5i <br /> � I � Wltrxsced removaQ <br /> q Iq I a.0 10 <br /> /S <br /> o" <br /> TOTALS <br /> BALANCE DUE: PAYMEN S TO BE RECEIVED 30 DAYS FROM THE BILLING DATE. <br /> PENALTIES WILL BE APPLIED TO PAST DU CCOUNTS 30 DAYS FROM BILLING DATE. <br /> RETURN ONE (1) COPY OF THIS BILL ALONG WITH PAYMENT. MAKE CHECKS PAYABLE TO: <br /> PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION (PHS-EHD). <br /> EH 23 074 (Rev 1/14/91) <br /> �ision of San Joaquin County Health Care Services 14 <br />