Laserfiche WebLink
BILLING RECORD FORM <br /> DBA: O C aCJ(GCiG / <br /> SITUS ADDRESS: 75 J <br /> PROGRAM: Lf-/ G S / SWEEPS# : <br /> COMP . # : <br /> BILL TO: -;1 <br /> NAME: ID <br /> ADDRESS : /Q <br /> CITY : A14 v ATE: (�19- ZIP: -- <br /> TITLE <br /> IP: --TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: Zn`Si ,V70J'r-1 <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/ CiERK <br /> HOLIDAYS <br /> TOTAL $ $ / HRS HRS HRS <br /> @ $35/HR @ 52 . 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ a C $ $ Less <br /> c <br /> CREDIT $ Credits <br /> DATE BILLING SUBMITTED: 7� BY: T/y BALANCE DUE $ }�! <br /> * Use for site assessment proposa s , wor p ans , e c. <br /> **Include travel ie for field services <br />