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SAN JOAOUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTHDIVISION <br /> v <br /> T SITE WASTE THER WASSESS NV(RON ASSESS TXER PILOT PROGRAM <br /> __SERVICES BILLING RECORD FORK _SITE SPECIFIC INVOICE <br /> EPS I ER / ROG/SUBELEMENT CODE .Z?�r. i 1TE CODE TROLELM Y / N <br /> c o <br /> OC [ODE "'� ISTR1Cf ) �i SSIGNED TO `_/�� RCE OF FUNDS STATE / FEDERAL <br /> SITE INFORMATION G SUBSTANCE <br /> ITE NAME 1y, .IQ� llP// ATE FIRST REPORTED DATE ENTER PILOT <br /> DRESS <br /> lTY / 21P NVOICE / <br /> BILLING/RESPONSIBLE PARTY INFORMATION <br /> tAME <br /> 'AILING ADDRESS / O/ ��✓ PHONE <br /> [TY STATE 21P <br /> TACT NAME C�FG JIIJCCC/// PNONE <br /> TYPE OF SUBMITTAL or <br /> ESCRIPTION OF SERVICE <br /> DATE RECEIVED l / / `. DATE OF SUBMITTAL /.7 / 6j / � T REQUESTED ATE OT REDUESTED <br /> SULT CK #/ MV/SB CK 0/ EMPLOYEE NAME kCTIVITY HOURS WORKED MILES TOTAL LABOR <br /> DATE IOTHER CASH PERMIT CASH CODE I COSTS <br /> EES PD FEE PD ST OT V/N <br /> 1 �s �2 <br /> LL <br /> CREDIT TOTAL ST HRS x S j /HR <br /> CREDIT OTHER PAGES _--- - TOTAL OT MRS x S - /HR S <br /> TOTAL CHARGES THIS SITE '+�62 TOTAL V/H HRS x S /HR <br /> ATE OF BILLING rOTAL CREDITS !2,S CK) TOTAL CHARGES THIS PAGE S <br /> EMITTED BY . .y LANCE DUE -rrZ�� TOTAL CHARGES OTHER PAGES /L�DJD <br /> EH 23 074 (5/89) TOTAL/MILE TOTAL CHARGES THIS SITE 2G Z- <br /> 89-OD6(IV)4/89 BILFRM <br />