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BILLING RECORD FORM <br /> DBA:-CAK/5v7J L /�. Z; <br /> SITUS ADDRESS : /'147 Zz)kS/ hand <br /> PROGRAM: �2GS7` SWEEPS# : a �� <br /> COMP . # : <br /> BILL T0: / - - <br /> NAME: C ��i -v- zS OC/ <br /> ADDRESS:- �O dt� o�fail <br /> CITY: STATE: C ZIP: <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <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 /> ✓f�( PqD.y�o WEEKDAYS WEEKNIGHTS HOLIDAYS CLERK <br /> a� <br /> a 7� <br /> TOTAL $ $ 13, <br /> HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> TOTAL $ (D I A 50 $ $ Charges <br /> CREDIT $ Less O '+% <br /> _ Credits <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE <br /> * Use for site assessment proposals , wor p ans , e c. <br /> **Include travel One for field services • <br />