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BILLING RECORD FO�RMM /J J�, / <br /> DBA: �ti 5C N & —��/-7U / ✓� • ' ' <br /> SITUS ADDRESS : _ 1EO(/ /U• l LG/�?G�Vyy[� GCS <br /> PROGRAM: (/l �S / SWEEPS# : �O <br /> COMP . # : <br /> BILL TO: <br /> NAME: <br /> ADDRESS : <br /> CITY: 1h� ajLi n STATE: ZIP : 703 <br /> TITLE OF SUBMITTAL 9 u L <br /> OR DESCRIPTION OF SERVICE: ( S�/< ( �n�� i��C�29 (J' f <br /> *DATE RECEIVED : *DATV OF SUBMITTAL : <br /> INIT'L � ADD'L CK#/ TOTAL HRS (use 1/4hr increments**) SANITARIAN <br /> DATE FEE PD ASH FEES CASH OR <br /> L PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> /��0 D�✓I HOLIDAYS <br /> 7 /&& S�°C o? Aho• <br /> ,5 1 folv� . <br /> q . <br /> 5 <br /> TOTAL $ $ HRS HRS NRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Tota 36 $�)- <br /> �7 / Charges <- <br /> TOTAL CREDIT $ $ 15 I7 $ U ` 0 $ Less 3� <br /> r <br /> � --- Credits IUS <�. <br /> hRs` <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE <br /> * Use for site assessment proposals , wor p ans , e Ec . <br /> **Include travel me for field services <br />