Laserfiche WebLink
LILLINGRECORD FORM <br /> DBA: r -- . C <br /> SITUS ADDRESS : <br /> PROGRAM• - GC'.C'� � <br /> SWEEPS# . 1364 <br /> BILL TO: .COMA . # : • G <br /> NAME• �k1U.ciJ r , <br /> ADDRESS ; <br /> CITY: 2ffi6ATIE <br /> ZIP : <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: ,;� <br /> *DATE RECEIVED: *DATE Q SUBMI AL : L <br /> INIT'L CK#/ ADD'L CKN/ TOTAL HRS (use 1/4hr increments ) SANITARIAN <br /> DATE FEE PD CASH FEES CASH <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ C OR <br /> HOLIDAYS <br /> Lr1 <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total � <br /> 01 <br /> TOTAL Ctiarge:�l c <br /> CREDIT $ $ $ Less <br /> Credits <br /> DATE BILLING SUBMITTED: :� f`,/�/� BY: <br /> ..�'.� BALANCE }DUE $ <br /> * Use for site assessment proposa s , wor pans , e C . <br /> **Include travel &e for field services <br />