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BILLING RECORD FORM 0 <br /> DBA:—u <br /> SITUS ADDRESS : A-7 W . <br /> y ! �( <br /> �'f a-41 <br /> PROGRAM: S_ .� SWEEPS# : <br /> BILL TO: <br /> NAME• <br /> ADDRESS : GGCJ ' <br /> CITY: TATE: cod ZIP : �3 <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATt OF SUBMITTAL : <br /> INIT'L CK#/ ADD' L CK#/ TOTAL HRS (use 1/4hr increment7) SANITARIAN <br /> DATE FEE PD CASH FEES CASH OR <br /> PD• WEEKDAYS WEEKNIGHTS WEEKEND/ Ci,ERK <br /> HOLIDAYS <br /> 7 Q <br /> TOTAL $ $ HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total Charges <br /> - <br /> TOTAL '' r` <br /> CREDIT $ S °� $ $ Less r, <br /> I>< Credits <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE <br /> * Use for site assessment proposals , wor p acts , -e-c . <br /> **Include travel t ,fie for field services <br /> I� <br />