Laserfiche WebLink
BILLING RECORD FORM <br /> DBS.: <br /> SITUS ADDRESS: <br /> —.- <br /> PROGRAM: SWEEPS# : <br /> BILL T0: <br /> ~ COMP. # : <br /> NAME: <br /> ADDRESS : <br /> CITY: �;,���vi1(�. STATE: _ ( ZIP: -/�10 <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/ C1,ERK <br /> HOLIDAYS <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35,/HR @ 52 . 50/HR @ $70/HR Total <br /> LDATELBILLING <br /> TA <br /> Charges <;,p <br /> EDIT $ $ $ $ Less a-b <br /> Credits " <br /> SUBMITTED: BY: BALANCE DUE $ <br /> * Use for site assessment proposals, wor p ans, <br /> **Include travel time for field services <br />