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ADMINISTRAWE HEARING FEE PAYMEI NFORMATION <br /> TO BE FILLED OUT BY STAFF ONLY <br /> FACILITY NAME FACILITY ADDRESS FACILITY ID# <br /> C�-�rL.n-� ila Ilp.,� lJu-vie.._ l� 2� �•'Tu tl.� '�2.m� <br /> EMPLOYEE# PROGRAM ELEMENT SERVICE CODE DATE OF HE NG P/R W# <br /> LpLp 552 N� <br /> V 7 2000 <br /> SANTO BE FILLED OUT BY ACCOUNTING ONLY PUB(j� -9U CO <br /> ENT4 HF kR�©/ES INVOICE# <br /> PAYMENT DATE FEE AMOUNT AMOUNT PAID HEC ASH RECEIVED BY <br /> t!/7/o0 Al 711 oo j7y. 70 1//i D74, �3� <br /> FEE(rPAY.FORM(7/00) <br /> Use the Program Record ID# with assigned invoice # on Daily Activity Record for activities to <br /> be charged against this facility <br />