Laserfiche WebLink
BILLING RECORD FORM <br /> A 1 <br /> SITUS ADDRESS : -39c) ,7 j <br /> PROGRAM: t G SWEEPS# ` <br /> BILL TO: COMP . # : + ? <br /> NAME: C� 7,f r ' <br /> ADDRESS ; <br /> CITY• STATE: _ ZIp :��t <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> INIT 'L CK#/ ADD'L CK#/ TOTAL HRS (use 1/4hr increments ) SANITARIAN <br /> DATE FEE PD CASH FEES CASK OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CjERK <br /> Vo-?Wo /4) --- -" HOLIDAYS <br /> P77 � - <br /> 36 <br /> a. <br /> ra— 104,.1.E <br /> -'} lJ l,sf— 3; D <br /> fes( <br /> mfrA/0 <br /> Z <br /> TOTAL $ $ HRS �+ HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total =�yc <br /> Chargpso� <br /> TOTAL r �y <br /> CREDIT $ l $ $ Less }� <br /> Credits <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE $ .� M <br /> * Use for site assessment propoals , wor sp ans , e c . <br /> **Include travel 4ke for field services <br />