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BILLING nRECORD FORM <br />ROA:- T/1L lTa� <br />SITUS ADDRESS: ( (Cy <br />PROGRAM: <br />BILL TO: o <br />NAME: CM4W&-/-t4 -rn C, <br />ADDRESS , D, as SD <br />CITY: .S>ojoJ, f��yytp_�, D, STATE: <br />TITLE OF SUBMITTAL <br />OR DESCRIPTION OF SERVICE: <br />*DATE RECEIVED: <br />SWEEP S#:� D <br />COMP.#: <br />*DATE OF SUBMITTAL: <br />ZIP: <br />DATE <br />INIT'L <br />FEE PD <br />CK#/ <br />CASH <br />ADD'L <br />FEES <br />PD. <br />CK#/ <br />CASH <br />TOTAL HRS (use 1/4hr increments) <br />SANITARIAN <br />OR <br />CLERK <br />WEEKDAYS <br />WEEKNIGHTS <br />WEEKEND/ <br />HOLIDAYS <br />TOTAL <br />$ <br />$ <br />HRS <br />a S HRS <br />HRS <br />@ $35/HR <br />@ 52.50/HR <br />@ $70/HR <br />Totall131, <br />Charges <br />TOTAL <br />CREDIT <br />$ <br />$ <br />$ <br />$ <br />Less <br />Credits <br />DATE BILLING SUBMITTED: BY: <br />BALANCE DUE <br />$ <br />x use ror site assessment proposals, worxpians, etc. <br />**Include travel time for field services <br />