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BILLING <br /> /RECORD FORM // 041 <br /> DBA: / 1�2 L(N� Z(/ 'Z'/4 G. <br /> SITUS ADDRESS : ZZY Z757 1,45/ 2 <br /> PROGRAM: T SWEEPS# : �— <br /> COMP. # :/d/ <br /> BILL TO: <br /> NAME: b <br /> ADDRESS: // ? 0 Uc ' <br /> CITY: t N 1 /O STATE: ZIP: Z <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: Z,l la X7 J /1;; 5 C�jjYt� L <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> ** <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 /> 010-qo <br /> 7o-la-90 <br /> fo <br /> 10-/4-F'0 v�e� <br /> ID a /✓Yo,�' SPe <br /> fo <br /> Ira740 <br /> i 3o-Q� i " <br /> - LU <br /> TOTAL $ $ / HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Tota <br /> 30�� <br /> Char C' <br /> TOTAL $ a OQ� g <br /> CREDIT $ J Less <br /> � Credit <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE $ 3 OC <br /> * Use for site assessment proposals, wor p ans , —e—c—. <br /> **Include travel *e for field services 0 <br />