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BILLING RECORD FORM • <br /> AHA• EL�ti. r a v `� _ <br /> SITUS ADDRESS : /Y o iv. �Fr, �4 e �Zrl Qg <br /> Mt?,vA,rr. C'h <br /> PROGRAM: 1/,5-57- SWEEPS# : Mo <br /> COMP. # : EkAt R/y <br /> BILL TO: <br /> NAME: oto. P2±M1e-q-w <br /> ADDRESS : P0.. &x 6'7 <br /> CITY: B�1411 STATE: C.4 ZIP : 5 c <br /> TITLE OF SUBMITTAL p <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/ CLERK <br /> HOLIDAYS <br /> it 29 $9 2 ,Sburr C f/u..'f" <br /> TOTAL $ $ a HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total /Poz <br /> Charges ., <br /> TOTAL $ $ $ Less <br /> CREDIT $ C <br /> Credits ' <br /> DATE BILLING SUBMITTED: ///30/07 BY : C"fF BALANCE DUE $7P <br /> * Use for site assessment proposals , wor p ans, -e-c. <br /> **Include travel time for field services <br />