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BILLING RECORD FORM <br /> DBA`. /�/�i0� lCE • • <br /> SITUS ADDRESS : <br /> PROGRAM: SWEEPS# : aV/ S� <br /> BILL T0: <br /> COMP. # : i./�. o.v y L <br /> NAME: <br /> ADDRESS . <br /> CITY: /?r }Ps/a STATE: CA ZIP : <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL : <br /> :FEEPID <br /> CK#/ ADD'L CK#/g <br /> ( use 1/4hr increments*) SANITARIAN <br /> DATE CASH FEES CASH OR <br /> PD. WEEKNIGHTS WEEKEND/ CuERK <br /> HOLIDAYS <br /> o <br /> I • <br /> TOTAL $ $ HRS HRS HRS <br /> @ S35/HRQ 52 . 50/HR @ $70/HR Total 3;_ <br /> Charges <br /> TOTAL <br /> CREDIT $ $ $ S Less <br /> _ Credits j <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE $ �i.vl <br /> * Use for site assessment proposals, wor p ans , etc. <br /> **Include travel one for field services 0 <br />