Laserfiche WebLink
BILLING RECORD FORM <br /> DBA• Fr i k s c4— y <br /> SITUS ADDRESS : �Frn,4 e- <br /> l' ,. /✓IQN�fC1. �� <br /> PROGRAM: /U6-'5 SWEEPS# : 9019 <br /> COMP- # : FRAn•KIY <br /> BILL TO: <br /> NAME: n1-P. P F±M ttkm <br /> ADDRESS : O, 8ax 611 <br /> CITY: R�� STATE: G4 ZIP : ?53c- <br /> TITLE <br /> 5 rTITLE OF SUBMITTAL 0 <br /> OR DESCRIPTION OF SERVICE: <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/ C1ERK <br /> HOLIDAYS <br /> it 2�9�9 2 /b-rr C 4"t <br /> I ' <br /> TOTAL $ $ HRS HRS HRS <br /> @ $355/HR @ 52 . 50/HR @ $70/HR Total 0 <br /> Charges <br /> TOTAL $ $ $ Less <br /> CREDIT $ _ Credits <br /> DATE BILLING SUBMITTED: // 30 $-� BY : C{f BALANCE DUE $np <br /> * Use for site assessment proposals, wor p atis , etc . / <br /> **Include travel time for field services <br />