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BILLING RECORD FORM <br /> DBA• /3 // /,// 5� • <br /> SITUS ADDRESS :_ 6%9q <br /> i <br /> PROGRAM: Me,e;7— SWEEPS# : y3/6 <br /> BILL T0: <br /> COMP. # : />i :c2 <br /> NAME: //Plic_ <br /> ADDRESS :— 1'7,7(, /tapy <br /> CITY• toe, STATE: ZIP : c` p� <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: r P0)1C✓t/ >//v i^p�/N�+l <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 /> 312-7170 <br /> 4 ,vT <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35./HR @ 52 . 50/HR @ $70/HR Total ro <br /> Charges <br /> TOTAL <br /> CREDIT $ $ $ $ Less <br /> Credits <br /> DATE BILLING SUBMITTED: BY: C BALANCE DUE $�j.5O <br /> * Use for site assessment proposals, wor p ans, e -c. <br /> **Include travel time for field services <br />