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BILLING RECORD FORM <br /> DBA <br /> SITUS ADDRESS : <br /> �qq <br /> PROGRAM: CSS T- SWEEPS# : <br /> COMP . <br /> BILL TO: NAME: # <br /> r <br /> �/{�"/'�!,lV�-,�-'r <br /> ADDRESS :_ gj PS <br /> CITY: k-f6, STATE : ZIP : %<Dj <br /> TITLE OF SUBMITTAL L <br /> OR DESCRIPTION OF SERVICE: �P_�`i<JlIr r►, ��r nN <br /> *DATE RECEIVED : ' *DATE OF SUBMITTAL : � w <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 /> I <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Totals c <br /> TOTAL $ $ <br /> CREDIT $ $ Charges <br /> Less �. <br /> Credits <br /> DATE BILLING SUBMITTED: 71'71"70 BYBALANCE DUE <br /> * Use for site assessment proposals , wor p ans , etc . <br /> **Include travel ne for field services <br />