Laserfiche WebLink
1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IUGT SITEI_' ' IHAZ WASTE! OT ER WASTE ASSESS, IERVIRON ASSESS OTHER. i PILOT PROGRAM <br /> I I r <br /> SERVICES BILL FORM SITE SPECIFIC INVOICE <br /> SWEEPS �, COMPUTER 1 PROG/SUBELEMEHT CODEJ A SITE CODE PETROLEUM Y / N <br /> IJ <br /> LOC CODE DISTRICT its ASSIGNED TOI, <br /> 1USOURCE OF FUNDS STATE / FEDERAL <br /> SITE INFORMATION SUBSTANCE <br /> SITE NAME �e DATE FIRST REPOR�d DATE ENTER PILOT <br /> ( <br /> (ADDRESS I � <br /> (CITY I S�oc f � i ZIP I INVOICE,f PAGE _OF <br /> I �i ; <br /> BILLING/RESPONSIBLE PARTY INFORMATION j�t OF SHEETS FOR THIS SITE <br /> SHAME S K ®efat�S <br /> {MAILING ADDRESS; S7� _ PHONE <br /> 1CITYI QP�Sf�L� STATE I ZIP <br /> T� <br /> CONTACT NAME( PHONE 15�) <br /> TYPE OF SUBMITTAL or <br /> DESCRIPTION OF SERVICEiI <br /> /��� <br /> DATE RECEIVED / / I DATE OF SUBMITTAL I / I / � ;OT REQUESTED( ,DATE OT REQUESTED <br /> CONSULT'CK i/'MW/SB ,CK i/; EMPLOYEE NAME ;EMPL ACTIVITY( HRS WORKED HOURLY RATES IN- TRAVEL TOTAL LABOR <br /> f DATE I/OTHER (CASH Iit CLASS( CODE DIR S PER COSTS <br /> FEES PDI �PIIIIT'CASH <br /> FEE PD iI CODE I ST OT W/HIST OT COST DIEM <br /> 531 <br /> y 3 <br /> 3 <br /> vi 'E' <br /> CREDITS I 'f TOTAL HRS <br /> CREDIT OTHER PAGES $ ; @ $ S _ <br /> I <br /> TOTAL CHARGES THIS SITE 1$ 7 5 _ I �111�iU <br /> @ $ <br /> DATE OF BILLING1�; /J� / (TOTAL CREDITS S TOTAL CHARGES THIS PAGE S ��Z. <br /> SUBMITTED BY; BALANCE DUE iS j�S �� TOTAL CHARGES OTHER PAGES S <br /> 1—z_/o-Ir 7 TOTAL CHARGES THIS SITE <br /> 0.9-ppf.riv�A.iAn RTI CRM <br />