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BILLING RECORD FORM <br /> DBA. <br /> SITUS ADDRESS : <br /> PROGRAM• U GS T- SWEEPS# : <br /> BILL T0: COMP. # : <br /> NAME: — <br /> ADDRESS : r' r.,CITY: Sixkiaw STATE: i' ZIP • --52, <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL : o <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 /> { 7T <br /> I <br /> TOTAL $ $ HRS HR HRS <br /> @ $3,/HR @ 52 . 50/HR @ 0/HR Totals <br /> TOTAL Charges <br /> CREDIT $ $ $ $ Less <br /> ——" Credits <br /> DATE BILLING SUBMITTED: _ 7 ';;, ";? BY : P BALANCE DUE , <br /> * Use for site assessment proposals , wor p aiis, etc . <br /> **Include travel t : for field services <br />