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" i3ILLING RECORD FORM <br /> V.W.r <br /> DBA: MoA-An ,—�1� y <br /> SITUS ADDRESS : tf2al E Mar, » Rc� <br /> 1;+C)e k+'tw CR <br /> PROGRAM: ({GST SWEEPS# : 1673 <br /> BILL T0: <br /> COMP . # • Mooesq <br /> /� <br /> NAME: (?e.1Oniff4� :Lee-LN"ic.s <br /> ADDRESS : 1601 R6er 94 <br /> CITY: Moniasfo STATE: Cq ZIP: 5:35 <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: /o a ,t n <br /> *DATE RECEIVED: *DATE OF SUB ITTAL . <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 <br /> Charges <br /> CREDIT $ <br /> TOTAL $ $ $ Less <br /> mac— Credits <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE <br /> * Use for site assessment proposals , wor p ans , etc. <br /> **Include trave*,.,ime for field services 1./ <br />