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W E S� STAR svc �J: <br /> ❑ON ACCOUNT <br /> ENV'IRPISIMENTAL, INC. RECEIVED DATE TECHNICIAN ❑COD <br /> SALES-CONSTRUCTION-SERVICE MAR 2 0 2013 4770 W. JENNIFER AVE. <br /> Lic * HAZ605142AB ❑CONTRACT <br /> 24 HOUR EMERG IVCY SERVICE FRESNO, CA 93722-64118 <br /> ENVIRONMENTALEALjH <br /> PERMIT/SERVICES (559) 277-9378 1 FAX(559) 277-0106 <br /> NAME OF SITE: BILLING NAME I, <br /> Authorize WSE to Perform Services per my Verbal Request. <br /> ADDRESS: ADDRESS: Position: <br /> Sign: Date: <br /> SITE PHONE NO: BILLING PHONE NO: CUSTOMER P.O.# <br /> REASON FOR VISIT: <br /> SERVICES RENDERED: <br /> INSPECTOR ON SITE: <br /> PART NO: DESCRIPTION SERIAL NO: QTY PRICE SUBTOTAL <br /> X <br /> X <br /> X <br /> X <br /> X <br /> X <br /> X <br /> � X <br /> SALES TAX % <br /> PART TOTAL: $ <br /> TIME & RATE <br /> ON SITE: X <br /> TRAVEL: X <br /> MILEAGE: X <br /> X <br /> TESTING X <br /> DATE TECH TIME IN TIME OUT SIGNATURE SURCHARGE/FEE X <br /> SUBTOTAL: <br /> TOTAL AMOUNT DUE $ <br /> I clearly understand and agree that all services are charged directly to me and that I am personally responsible for payment I understand that if I suspend or terminate work,all fees <br /> for services will be immediately due and payable. I understand that UCC1 will be filed on the property and its owner. In the event of my default of payment, I promise to pay legal <br /> interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection. <br /> DATE CUSTOMER SIGNATURE POSITION PRINT NAME <br />