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BILLING RECORD FORM <br /> C <br /> DBA: ) / ;� <br /> / /U �/J17�` ' •► <br /> SITUS ADDRESS : l�D(J /U• l GIiGGi`"&14't'ict� <br /> PROGRAM: (/! C9J SWEEPS# : 10 <br /> COMP . # : <br /> BILL TO: <br /> NAME: <br /> ADDRESS : <br /> CITY : '1-2/1 lith STATE: ZIP : 70 j <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: !J� L�D�n�Uri/a��CZZ9 0�O,����LPJ <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> ** <br /> INIT 'L K ADD'L CK#/ TOTAL HRS (use 1/4hr increments ) SANITARIAN <br /> DATE FEE PD ASH FEES CASH OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> 13(p� 005 HOLIDAYS <br /> 3 a � <br /> hre/r Z{7 r7 — <br /> r <br /> 5 <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Tota 3� <br /> Charges <`s <br /> TOTAL $ 157 �- s l Q $ Less <br /> CREDIT $ <br /> CreQits <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE $ ` <br /> * Use for site assessment proposals , wor p ans, etc- . <br /> **Include travel time for field services <br />