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n <br /> SAN' JO�UI.N :LOCAL HEALTH ' DIST ,,,�Z` <br /> T SITE WASTE THER UASTE.ASSESS WINON ASSESS ( ETHER PILOT PROGRAM '\ <br /> SERVICES BILLING RECORD FORM SITE SPECIFIC INVOICE <br /> EPS �MPUTER It e5 �ROG/SUBELEMEE T CODE C�3• $'Q ITE CODE X333 TROLEUI 0 N I <br /> CODE ISTRICT �SSIGNED TO SOURCE OF FUNDS So <br /> TAT / FEDERAL <br /> SITE INFORMATION SUBSTANCE f ? 21 <br /> ITE MANE ATE FIRST REPORTED DATE ENTER PILOT <br /> E <br /> kDD <br /> RESSC2610 s. /.aa /8� <br /> ITY ,/CGv ZIP =?5 <br /> NVOICE 0 AGE _ OF <br /> BILLIMO/RESPONSI9CE PARTY'IMFORMAYIOH••. f, <br /> F.SRETS:FOR:XPA4'SITom <br /> E;, 5 <br /> 'L'r'r•� lt/ / " l <br /> I LI NG ADDRESS 5 z/� �. PSE <br /> ITY STATE IC ZIP <br /> TACT NAME ear PHONE <br /> V145T std_b6 3 <br /> YPE OF SUBMITTAL or ,nn <br /> ESCRIPTION OF SERVICE /=E - FKc,4✓A-T7vn7 AAJ-6 Solt- �/�-/�N� /�vV' 11\IsPL5G71OA-� <br /> DATE RECEIVED / / DATE OF SUBMITTAL / / T REOUESTED ATE OI REGIIESTED <br /> SULT !/ /SB CK !/ EMPLOYEE NAME L kCTIVITY HRS WORKED HOURLY RATES N- RAVEL NOTAL LABOR <br /> DATE fOTHER 31ERMIT CASH LASS CODE )IR4PER COSTS <br /> EES PD EE PD E ST OT /H ST OT DIEM R <br /> g <br /> �/9 C! . ver✓E��q /�S <br /> -vL�✓ErRr4- Ia4p 0.15 <br /> i <br /> f <br /> CREDIT 9 TOTAL HRS f <br /> CREDIT OTHER PAGES & = <br /> OTAL CHARGES THIS SITE 9 0 1 to <br /> 1� s <br /> P <br /> ATE OF BILLING / / OTAL CREDITS TOTAL CHARGE !GE ' <br /> ITTED By LANCE DUE TOTAL C GES EH 00 04 (5/89) TOTAL CHARGES THIS S <br /> 89-006(IV)4/89 BILFRM <br />