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bl"ING RECORD FORM <br /> DBA: ' Un,ryPrs�•l� k'i'N�Je Cm foo <br /> SITUS ADDRESS :Q56 rN�I„�1l ►� x'/5209 <br /> PROGRAM:_ <br /> SWEEPS# : /. <br /> BILL TO: COMP . # : F <br /> NAME: _ CrMCO <br /> ADDRESS <br /> CITY: AAm�?p STATE: ?ro • <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: J.-k fZt'/7b(t(/ Sjrc �jON <br /> *DATE RECEIVED: *DAT OF SUBMITTAL : <br /> INIT'L CK#/ ADD 'L CK#/ TOTAL HRS ( use 1/4hr increments*) SANITARIAN <br /> DATE FEE PD CASH FEES CASH <br /> OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> � tial/' C �uNfi <br /> TOTAL $ $ HRS I HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total'5 7.zZ <br /> TOTAL <br /> Charges <br /> CREDIT $ $ $ $ Less i <br /> Credits <br /> Y .J <br /> DATE BILLING SUBMITTED:_ BY : 't_ BALANCE DUE $ j <br /> * Use for site assessment proposals, wor p ans, -eFc—. <br /> **Include travel time for field services <br />