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BILLING RECORD FORM <br /> D$A' <br /> SITUS ADDRESS :_ <br /> C <br /> PROGRAM: 1 SWEEPS# : <br /> BILL T0: <br /> COMP. <br /> NAME: l�t <br /> ADDRESS : a11:?10 F2,\ <br /> CITY:( •-` a STATE: ZIP: <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE:-bell) <br /> *DATE RECEIVED: *DATE OF SUBMITT <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/ CuERK <br /> HOLIDAYS <br /> 1 .0 H Ta, <br /> TOTAL $ $ HRS HRS HRS <br /> @ $3,5/HR @ 52 . 50/HR @ $70/HR Total ( . <br /> TOTAL <br /> Charges <br /> CREDIT $ $ � � $ $ Less <br /> _ Credits <,~, <br /> DATE BILLING SUBMITTED:_ - �� �� BY: `.a BALANCE DUE $ <br /> * Use for site assessment proposals, wor p ans, e -c. <br /> **Include travel e for field services 41 <br />