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w� w <br /> BjjjLING RECORD FORM <br /> DBA: s xa,a C4 <br /> SITUS ADDRESS : ycsoc> <br /> PROGRAM:Jd6 „_ _ _ SWEEPS# : 6Oo <br /> BILL TO: <br /> COMP . # : <br /> NAME: Moom ofeaw <br /> ADDRESS : d. 62 <br /> CITY: _�a,��-u_ 4 STATE: C ... ZIP: C0` <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <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 /> 17000 S <br /> TOTAL $ $ OSo-� HRS HRS HRS <br /> @ $35/HR @ 52. 50/HR @ $70/HR Tota <br /> TOTAL <br /> Charges <br /> - <br /> CREDIT $ $ $ $ Less <br /> Credits <br /> [LATE BILLING SUBMITTED: 2. BY : BALANCE DUE $ <br /> * Use for site assessment proposals , wor p ans , etc . <br /> **Include travel time for field services <br />