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BILLING RECORD FORM <br /> DB-A: <br /> SITUS ADDRESS : o^�6S S ArrQor� <br /> PROGRAM: YNd\2r t-d S4o1r -rA -tis SWEEPS# : 121 <br /> COMP. # : RA/N2R6 <br /> BILL T0: <br /> NAME: Q(W22/V <br /> ADDRESS : <br /> CITY: w'�y STATE: ZIP: 95'd <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: :X i l m41, e SNs�ec Froin Se fxrrnG gro'h SNSPfc�k1� <br /> *DATE RECEIVED: ATE OF SUBMITTAL: f <br /> ** <br /> INIT'L CK#/ ADD'L CK TOTAL HRS (use 1/4hr increments ) SANITARIAN <br /> DATE FEE PD CASH FEES SH OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> HOLIDAYS <br /> TOTAL $ S o o $ 3 c:- HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total i.,150 <br /> Charges ;v <br /> TOTAL $ $ Less 3;r <br /> CREDIT $ c ' <br /> Credits <br /> DATE BILLING SUBMITTED: BY : BALANCE DUE $?750 <br /> * Use for site assessment proposals , wor p ans , etc . <br /> **Include travel time for field services <br />