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BILLING RECORD FORM <br /> DBA:_ <br /> SITUS ADDRESS : <br /> PROGRAM:_ GlC j jr SWEEPS# : /' <br /> BILL T0: COMP. # : ��C ��7 ,2 <br /> NAME: / �'si���� s 5����fc� ���c` <br /> ADDRESS : u <br /> CITY: STATE: C�6� ZIP : 9y& � <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> TV— <br /> INIT 'L CK#/ ADD 'L CKff/ 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 $ $ �2 HRS HRS HRS <br /> @ $3,5 HR @ 52 . 50/HR @ $70/HR Total 70,00 �L <br /> TOTALCharges <br /> CREDIT $ $ 7(i C o $ $ Less <br /> Credits <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE $ <br /> * Use for site assessment proposals , wor p ans , etc. <br /> **Include travel time for field services <br />