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SVC NO: O.Mo Billable
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<br /> DAP co
<br /> DATE: �" i'.M TECHNICIAN: t ✓ ' T` 3 t7 WSE w
<br /> ENVIR MENTAL INC.. .
<br /> SALE CO TRLf ON-SERVICE COD CD
<br /> Lie A- 04. 4688 W.Jennifer Ave.,*101LD
<br /> 24 HO MERGE YSERVICE Fresno,CA 93722-64118
<br /> 559-277-93781 Fax 559-277-0106 m
<br /> CUSTOMER NUMBER: °
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<br /> NAME OF SITE: ', �.>; : ;_^� ' BILLING NAME:
<br /> ! { Authorize'VJSE to Perform Services per my Verbal Request.
<br /> ADDRESS:
<br /> ADDRESS:
<br /> ;< :?Y - `- Sign: - Date. m
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<br /> SITE PHONE NO: -;._ �,1 nom' r ,f BILLING PHONE NO: CUSTOMER P.O. #; i,3
<br /> EQUIPMENT SERVICEDICOMPLAINT: i¢. � .. `" `` ODOD
<br /> CORRECTIVE ACTION TAKEN: 4Q f $ ' % "r` s_C'+ 3r
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<br /> clearly understand and agree that all services are charged directly to me and that I ani personally responsible for payment I understand that if I
<br /> suspend or terminate work, all fees for services will be immediately due and payable. 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 /> CD
<br /> PRINT NAME
<br /> DATE - .{f CUSTOMER SIGNATURE - — —”--
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