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BILLING RECORD FORM <br /> Site Name �L l s ��LaA S 4� S, <br /> Address e,,��c ss c�(. L20 - c_c, Phone 'Slx--,f - .00 0 <br /> Program _ So ! e ts'! lit/a s �l'c_ Sweeps # l .3 <br /> Bill To: Name Scs42 94c,cLa/t� C�, C-a a te, 1 c <br /> Address �• Q / �' <br /> City. . s'�`- r_�f o,2 State C4 7 iP -,-21 U <br /> B <br /> Date Hours Worked Type of Work REHS <br /> t <br /> -54 5 2 0 <br /> ^( c�� <br /> J <br /> l ty e� <br /> C <br /> I i <br /> I <br /> t <br /> i <br /> i <br /> t ; <br /> i <br /> ( <br /> Total 9 Hrs <br /> @ 35/Hr i <br /> Total <br /> Cost Date of B' lling Submittecl � <br /> �1) By � L� : <br />