Laserfiche WebLink
BILLING RECORD FORM <br /> w ry <br /> DBA: <br /> SITUS ADDRESS : l <br /> Lo C <br /> PROGRAM: [1t C' -S 7— SWEEPS# : <br /> COMP . # : <br /> BILL TO: <br /> NAME: <br /> ADDRESS ` <br /> CITY` STATE: ZIP: <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 /> a y <br /> TOTAL $ $ J4 2 HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ �, $ $ Less �. <br /> CREDIT $ Credits � <br /> [D:A:T:EBILLING SUBMITTED: y`J BY : BALANCE DUE $J�_ <br /> * Use for site assessment proposals , wor p ails , e c . <br /> **Include travel We for field services <br />