Laserfiche WebLink
. 1 <br /> SAN JQtiN COUNTY ' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> T SITE WASTEL....................... THER WASTE ASSESS <br /> NVIRON ASS1 SS THER <br /> PILOT PROGRAM <br /> SERVICES BILLING RECORD FARM <br /> EPS # <br /> _SITE SPECIFIC INVOICE <br /> ER '. <br /> ROG/SUBELEMENT CODE ' ITE CODE <br /> A L ETROLEUM Y / N <br /> OC CODE l� lS7RICT SSIGNED TO <br /> RCE OF FUNDS STATE / FEDERAL <br /> SITE INFORMATION <br /> SUBSTANCE <br /> ITE NAME -� <br /> ATE FIRST REPORTED DATE ENTER PILOT <br /> DRESS <br /> ITT <br /> 2IP MVOICES AGE OF <br /> BILLING/RESPONSIBLE PARTY INFCRlUITION <br /> iLING ADDRESS <br /> PHONE <br /> It TY J « C �i q <br /> G-v3 STATE ZIP /�S 0.T7U . <br /> TACT NAME /1 / - A ,� <br /> (� Oc/�Ct �f- PHONE <br /> TYPE OF SUBMITTAL or <br /> ESCRIPTION OF SERVICE <br /> 62 <br /> OATS RECEIVED / / DATE OF SUBMITTAL / / T REQt1ESTED [ATE OT REQUESTED <br /> SULT CK 1Y/ MI CK #/ EMPLOYEE NAME• CTIVITY HOURS WORKED MILES TOTAL LABOR <br /> DATE OTHER CASH PERMIT CASH , CODE COSTS <br /> EES PD FEE PD ST OT Y/H <br /> 1 <br /> CREDIT TOTAL ST MRS x f /HR <br /> CREDIT OTHER PAGES TOTAL OT HRS I x S /HR <br /> OTAL CHARGES THIS SITE 9 TOTAL Y/H MRS x S /HR <br /> ATE OF BILLING rOTAL CREDITS TOTAL CHARGES THIS PAGE <br /> EMITTED BY I rALANCE DUE TOTAL CHARGES OTHER PAGES <br /> EH 23 074 (5/89) TOTAL MILE TOTAL CHARGES THIS SITE <br /> 89-DD6(IV)4/89 BILFRM <br />