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BILLING RECORD FORM <br /> DBA'__ <br /> SITUS ADDRESS : //Ctq /U- <br /> PROGRAM: % G-- SWEEPS# ' <br /> J� COMP. # : <br /> BILL TO: <br /> NAME: iADDRESS : /✓ C�?i�sn <br /> CITY' S-17,r/r' [, STATE:' ZIP : 95b2 ]s— <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 /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> TOTAL $ $ / HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total¢5�7,5� <br /> Charges <br /> TOTAL $ $ $ Less <br /> CREDIT $ Credits <br /> DATE BILLING SUBMITTED: BY : C'v� BALANCE DUE <br /> * Use for site assessment proposals , wor i5 axis , etc. <br /> **Include travel *e for field services • <br />