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FEE PAYMENT INFORMATION <br /> Use for consultations, reinspections, chargeable complaint inspections and/0 ad arings at INVEYT06Ebrf1 <br /> FACIUTIES: ��` •J <br /> 1. Fill out Boxes 1 through 7. <br /> 2. Submit to ACCOUNTING OFFICE with fee paid. <br /> 3. The ACCOUNTING OFFICE will receipt payment (Boxes 9 through 15), assign ; ;Box 8) and forward to <br /> the REHS staff person. <br /> 4. The assigned INVOICE # will be used with the facility's PROGRAMM/ATER RE laily activity record for <br /> activities to be charged against this fee. <br /> FACUTY: ID# RECORD IE) # <br /> FACILrry ADDRESS 3 I? 4CA�5Eu Qom, S Cp d <br /> DESIGNATED PROGRAM ......<:i:5>:`: <br /> . <br /> luvoiclr <br /> EMPLOYEE # ELEMENT CODE <br /> ''<`s>.'> SERu(CE?`.» ?> <br /> ECELATE OF 1Pi REGV? <br /> PAYMENT AMQUN E 1�AIQ.; tPE. <br /> y0, �w <br /> WAF7" <br /> uaMrrrED NR ::;: :: ccaU/(T1NC' Nti N(T <br /> ay 9tPv19 EN10H OFRC£ I I-LH+K SI'AW <br /> y <br /> DATE DATE DATE '�? ;:: DATE �•.i IZl7F -. <br /> F EPA .FRM ( /1 / 4) t I <br />