Laserfiche WebLink
BILLING RECORD FORM <br /> - DBA'. Frr= L�' <br /> SITUS ADDRESS : <br /> � E <br /> PROGRAM:��)� SWEEPS# : STOCK <br /> COMP . # : 5 <br /> BILL TO: <br /> NAME: <br /> ADDRESS : <br /> CITY: STATE: C4 ZIP: -2520-5 <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> INIT'L CK#/ ADD'L CK#/ TOTAL MRS (use 1/4hr increments*) SANITARIAN <br /> DATE FEE PD CASH FEES CASH OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> TOTAL $ $ I (; HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges ti <br /> TOTAL -C ' <br /> CREDIT $ $ 73' ' $ $ Less <br /> Credits <br /> DATE BILLING SUBMITTED: Z/H O BY : t�� -� BALANCE DUE $��5� <br /> * Use for site assessment proposals , wor p ans , e c. <br /> **Include travel me for field services <br /> . J <br />