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BILLING RECORD FORM <br /> ABA: 5/ �� <br /> SITUS ADDRESS : <br /> PROGRAM: «�-_ SWEEPSp : <br /> BILL TO: COMP . # : �cIq T--s- / <br /> NAME: <br /> ADDRESS :_ <br /> CITY: STATE: 04 ZIP : <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: ` A <br /> *DATE OF SUBMITTAL : <br /> INIT 'L CKN/ 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 /> rile 7 <br /> TOTAL $ r s _'_ $ <br /> HRS HRS HRS <br /> @ $355/HR @ 52 . 50/HR � @ $70/HR Tot41A�,s� <br /> TOTAL $ $ Charzjes a; <br /> CREDIT $ $ Less <br /> Credits 4 <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE ( <br /> * Use for site assessment proposa s, wor p ans , e c. <br /> **Include travel t 0 for field services • d <br />