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BILLING RECORD FORM • <br /> DBA: kl f e �T+�f <br /> SITUS ADDRESS : :zGt-/ COCAC� <br /> S**—k- O rJ CA 2c.22-05— <br /> PROGRAM: <br /> 205'PROGRAM: WLGS� _� SWEEPS# : 2y6( <br /> COMP . # : •DrRAl- <br /> BILL TO: <br /> NAME: J6 '11 <br /> c-o -�-��- <br /> ADDRESS . -77 u/ i3ri,rc <br /> CITY: Swj. ROIL STATE: rte¢ ZIP :7-%y <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/ CLERK <br /> HOLIDAYS <br /> � izJ9c?. <br /> 7) 90 <br /> rLn %i <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35./HR @ 52 . 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ $ $ Less <br /> CREDIT $ Credits <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE $a� <br /> * Use for site assessment proposals , wor p ans , -e-c- . <br /> **Include travel t-0 for field services • <br />