Laserfiche WebLink
` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �GT SITE I ✓ AZ WASTE �THER WASTE ASSESS IE <br /> NVIRON ASSESS IDTHER PILOT PROGRAMT�j <br /> SERVICES BILLING RECORD FORM SITE SPECIFIC INVOICE <br /> WEEPS # (/ OMPUTER # , 1 7 Gj ROGJSUBELEMENT CODE 47� SITE CODE ETROLEUM Y / N <br /> OC CODE ISTR3CT sz o SSIGNED TO fOJSOURCE OF FUNDS STATE / FEDERAL <br /> SITE INFORMATION SUBSTANCE <br /> ITE NAME ATE FIRST REPORTED DATE ENTER PILOT <br /> DRESS X456 ��. �rT /1� C�'�✓ f�_i J J J J <br /> ITY �/t _ , y� / ZIP 1NVO7CE # AGE OF <br /> BILLING/RESPONSIBLE PARTY INFORMATION <br /> AME I 1,�,, <br /> -tAILING ADDRESS -Z 7 PHONE <br /> ITYU, Qat STATE �+ ZIP �} <br /> ONTACT NAME c� PHONE <br /> YPE OF SUBMITTAL or <br /> ESCRIPTION OF SERVICE } <br /> DATE RECEIVED I 7 / ? / DATE OF SUBMITTAL 17 J T REQUESTED ATE OT REQUESTED / J <br /> ONSULT CK #/ MW/SB CK #/ EMPLOYEE NAME CTIVITY HOURS WORKED MILES OTAL LABOR <br /> DATE tOTHER CASH PERMIT CASH CODE COSTS <br /> EES PD FEE PD ST OT W/H <br /> 2-70' 5'-7LZ- y <br /> CREDIT TOTAL ST HRS 1 x $ �{ /HR � fi7 <br /> CREDIT OTHER PAGES TOTAL OT HRS x $ /HR {? <br /> TOTAL CHARGES THIS SITE TOTAL W/H HRS �)' x $ /HR <br /> ATE OF BILLING fOTAL CREDITS TOTAL CHARGES THIS PAGE <br /> UBMITTED BY ALANCE DUE TOTAL CHARGES OTHER PAGES <br /> EH 23 076 (5/89) TOTAL MILE TOTAL CHARGES THIS SITE <br /> 89-006(IV)4/B9 BILFRM <br />