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BILLING RECORD FORM <br /> DBA: C C� <br /> SITUS ADDRESS : � � h�rC:��n_ _ 1 � <br /> � SWEEPS# : � <br /> PROGRAM: COMP . # : <br /> BILL TO: <br /> NAME: �� �� , <br /> ADDRESS : TATE' <br /> T'rf'r Z I P : �✓ <br /> CITY : lA �TITLE OF OF SUBMITTAL t <br /> OR DESCRIPTION OF SERVICE: �� *DATE OF SUBMITTAL : <br /> *DATE RECEIVED: ** <br /> 7DATEFEE <br /> NIT'L CK#/ ADD'L CK#/ TOTAL HRS (use 1/4hr increments ) SANITAARIAN <br /> OR <br /> PD CASH FEES CASH C�,ERK <br /> PD. WEEKDAYS WEEKNIGHTS WEEKENDD/ <br /> HOLIDAYS <br /> A� J� � <br /> 44 � i 10 <br /> TOTAL $ $ ,p HRS l,b HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total t. <br /> Charges <br /> $ b $ S� s� <br /> $ Less { <br /> TOTAL Credits <br /> CREDIT $ <br /> DATE BILLING SUBMITTED: 11 Zk BYBALANCE DUE <br /> . <br /> * Use for site. assessment proposa s , wor p ails , e c- <br /> **Include trave0ime for field services <br />