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4,A PAYMEN1 <br /> �� PAYMENT INFORMATION �1 <br /> Use for consultations, rernspections• c�FEE <br /> sable com _laint ins tions and/or administrafve f s gptlWTORIED <br /> FrIFS' <br /> ' Fill out Boxes 1 through 7. SAN JoAoulNcouNTr <br /> HEALTH SERVICES <br /> 2. Submit to ACCOUNTING OFFICE with fee paid. vl PUBLIC EHH HEA r olvlslo <br /> 3. The ACCOUNTING OFFICE will receipt payment (Boxes 9 through 15), assign an INVOIdt W9Wox*anPOrwarg to <br /> the REHS staff person. <br /> 4. The assigned INVOICE # will be used with the facility's PROGRAWWATER RECORD ID on daily activity record for <br /> activities to be charged agai//nsst this fee. q <br /> FACILITYID # t V V [-7D l F�ECOaD ID # ' 1 (Ono <br /> FIICIUTY'AODItESS lb 3-7 <br /> i, OESIGNATEO. PROGRAM <br /> ER C8 <br /> DATE �� INVOICE <br /> EMPLOYEE # ELEMENT: CODE SERVICE # <br /> _- <br /> 4 <br /> DATE OF FEE AMOUNT PAYMENT R@CEII'T CHECK IE�VO <br /> PAYMENT AMOUNT >PAID::::: TYPE'' <br /> • aQ! ;'EY <br /> i 1 <br /> 10 11 11 t Ia <br /> CCO�MIpW <br /> Nlf <br /> . ,:: 9tl.vl9n+�olt <br /> 811t <br /> L)ATF >. DATE" <br /> DAti <br /> DAtt <br /> EEi A1T.F�tv1 i571�%�41 . <br />