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BILLING RECORD FORM <br />DBA: <br />SITUS ADDRESS: IZ7" <br />PROGRAM: <br />BILL TO: <br />NAME: <br />ADORE <br />CITY: <br />A <br />SWEEPS#: /� D <br />COMP. #: F,�lcv4 <br />TITLE OF SUBMITTAL <br />OR DESCRIPTION OF SERVICE: <br />*DATE RECEIVED: <br />*DATE OF SUBMITTAL: <br />DATE <br />INITIL <br />FEE PD <br />CK#/ <br />CASH <br />ADD'L <br />FEES <br />PD. <br />CK#/ <br />CASH <br />TOTAL HRS (use 1/4hr increments*) <br />SANITARIAN <br />OR <br />CLERK <br />WEEKDAYS <br />WEEKNIGHTS <br />WEEKEND/ <br />HOLIDAYS <br />/lz� <br />t3nJKlSC� <br />ATOTAL$ <br />$ <br />4- HRS <br />HRS <br />HRS <br />@ $3�5/HR <br />@ 52.50/HR <br />@ $70/HR <br />Total <br />TOTAL <br />CREDIT <br />$ <br />$ <br />$ <br />$ <br />Charges <br />Less <br />Credits <br />_ <br />DATE BILLING SUBMITTED: BY: <br />* 11-- 4 . <br />BALANCE DUE <br />$ <br />**Include travel time for field services <br />