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BILLING RECORD FORM <br /> DhA: -AM/ L'l � tl lTy �� D• ��o�iC ) <br /> SITUS ADDRESS : FP-: o l n r �Y r�7in^OJ{t ) �ilv <br /> PROGRAM: C ISI SWEEPS# : <br /> COMP . # : A7ZCCR�I Z <br /> BILL TO: <br /> NAME: ' iLT1)!J NF f,1 Or�1 <br /> ADDRESS • c N'(_ <br /> CITY: ,T SFr--0,H+e-Ur7r--) STATE: <J=t ZIP: q;3l09 <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: Ihf liT�1, cls'. �t' `� IU_h-ili�a_) i!- <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 /> I I <br /> TOTAL $ $ / L, HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ $ $ r <br /> CREDIT $ Less r., <br /> _ — Credits <br /> DATE BILLING SUBMITTED: /4-< BY : - BALANCE DUE $- <br /> ;?fir <br /> * Use for site assessment proposals , wor p ans , TE—c . <br /> **Include travel time for field services <br />