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BILLING RECORD FORM <br /> DBA: �L7C��>r �5 • <br /> SITUS ADDRESS : <br /> � �/l�/ 7--- e4 95aos-- <br /> PROGRAM: �iSl SWEEPS# : <br /> BILL TO: � COMP . # : <br /> NAME: r LI, E o <br /> ADDRESS fid, ,BOX <br /> CITY: _ S1- -4J STATE: C'¢ ZIP :7 21'z <br /> TITLE OF SUBMITTAL / <br /> OR DESCRIPTION OF SERVICE: _ Vii) <br /> *DATE RECEIVED: <br /> ' *DATE OF UBMITTAL :_ (,t <br /> INIT'L CK#/ ADD'L CK#/ TOTAL HRS ( use 1/4hr increments*) SANITARIAN <br /> DATE FEE PD CASH FEES CASH <br /> PD. WEEKDAYSOR <br /> WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> TOTAL $ $ HRS HRS HRS C <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total 70.06 <br /> TOTAL Charges <br /> CREDIT $ $ <br /> � $ $ Less r` <br /> Credits <br /> DATE BILLING SUBMITTED: 5/2,14p BY : C4_ <br /> Use BALANCE DUE $ pp <br /> * for site assessment proposals , wor p ans , e c . �D' ' <br /> **Include travel tifor field services <br />