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BILLING F.2CORD FORM / <br /> DHA: P2\/ dee 1/t%LI,c L_V <br /> SITUS ADDRESS :_ 1 -700 lV Qdl lit//j,/ S�(jGlL7jf/ 5J-30S� <br /> PROGRAM: SWEEPS# : Xypl ,-7 <br /> 2 <br /> BILL T0: COMP. # :-�- f-_ / <br /> NAME: VOTCo Fe+yoje(A✓H £&N1 60 <br /> ADDRESS <br /> CITY: ATI A %r- STATE: ZIP: <br /> /55� <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 CASH OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> la-t�-9v � ✓�� �v <br /> I <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ $ $ Less <br /> CREDIT $ Credits ^, <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE <br /> * Use for site assessment proposals, wor p ans , e C . <br /> **Include travel,ime for field services <br />