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BILLING RECORD FORM <br /> A <br /> DBA: � s - X <br /> SITUS ADDRESS : yl�0o (,tJ <br /> u <br /> PROGRAM: 6-5SWEEPS# : 1600 _ <br /> COMP . # ' <br /> . BILL T0: <br /> NAME: Moom Pekofeuv, <br /> ADDRESS : F0. &-)Y---6'7 <br /> CITY: r.►�ago <br /> STATE: ZIP: <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL : <br /> ** <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 /> ifxz o 20o9 Ars <br /> (1231q, <br /> TOTAL S $ S nv HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Tota 4 <br /> Charges <br /> TOTAL $ $ $ Less <br /> CREDIT $ Credits ' <br /> DATE BILLING SUBMITTED: I/-?yRD BY :� � BALANCE DUE <br /> * Use for site assessment proposals , war p axis etc. <br /> **Tnr•1 iiria -ravel time for field services <br />