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BILLING RECORD FORM <br /> DBA: Lxrr ` - tip/ <br /> SITUS ADDRESS : d =- <br /> PROGRAM:�f^)( __ _ SWEEPS# : Ca' <br /> COMP . # : <br /> HILL TO: <br /> NAME: r y:L,.1 ' f.UDr ��OYJS <br /> ADDRESS : <br /> CITY: STATE: ZIP : <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: 616 T- l[ A4r� A <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 I OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ I CLERK <br /> HOLIDAYS <br /> l ,C; <br /> 1(3a� � <br /> fol <br /> TOTAL $ $ JS HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges ,, <br /> TOTAL $ 7, 5 $ $ Less <br /> CREDIT $ <br /> �-- Credits <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE <br /> * Use for site assessment proposals , war p ans , e c . <br /> **Include travel We for field services 41 <br />