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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> WASTEF �TH GT SITE F ER WASTE ASSESS 7NVIRON ASSESS THER PILOT PROGRAM <br /> SERVICES BILLING RECORD FORM SITE SPECIFIC INVOICE <br /> WEEPS # OMPUTER # ROG/SUBELEMENT CODE '7'7 i.� i SITE CODE ETROLEUM Y / N <br /> L-L <br /> OC CODE ISTRICT Y 3 y SSIGNED TO SOURCE OF FUNDS STATE / FEDERAL <br /> i <br /> SITE INFORMATION SUBSTANCE <br /> ITE NAME ATE FIRST REPORTED DATE ENTER PILOT <br /> DRESS V�', BrD6k�71 <br /> ITY ZIP INVOICE # AGE OF <br /> BILLING/RESPONSIBLE PARTY INFORMATION <br /> AME <br /> L l i i /17 L <br /> !LING ADDRESS PHONE <br /> 4�v 2tA lou✓ /5> 52- Sou <br /> ITY C STATE ZIP4- <br /> ON TACT NAME PHONE <br /> TYPE OF SUBMITTAL or <br /> ESCRIPTION OF SERVICE <br /> z <br /> DATE RECEIVED / / DATE OF SUBMITTAL /�S/ T REQUESTED ATE OT REQUESTED / / <br /> ONSULT CK #/ MW/SB CK #/ EMPLOYEE NAME CTIVITY HOURS WORKED MILES TOTAL LABOR <br /> DATE OTHER CASH PERMIT CASH CODE COSTS <br /> EES PD FEE PD ST OT W/H <br /> , <br /> CREDIT TOTAL ST HRS x $ <br /> 5 /HR <br /> CREDIT OTHER PAGES TOTAL OT HRS x $ /HR b <br /> TOTAL CHARGES THIS SITE t e TOTAL W/H HRS x $ /HR <br /> ATE OF BILLING �-/ I(� / eQc' TOTAL CREDITS 35 C c TOTAL CHARGES THIS PAGE <br /> SUBMITTED BY \ ALANCE DUE 7U oa TOTAL CHARGES OTHER PAGES <br /> EH 23 074 (5/89) TOTAL MILE TOTAL CHARGES THIS SITE <br /> 89-006(IV)4/89 BILFRM <br />