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f <br /> ANG RECORD FORM <br /> `c <br /> SITUS ADDRESS: 5p537(� <br /> PROGRAM: SWEEPS# : <br /> COMP. # : T.e,44.0 <br /> BILL T0: 54L=LC._ OIL CO. <br /> NAME• .• �� -� <br /> ADDRESS: <br /> CITY: e STATE: CA ZIP: q-'—zc -2� <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> J * <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 /> 3,0 <br /> TOTAL $ $ HRS j° HRS HRS <br /> @ $35,/HR @ 52 . 50/HR @ $70/HR Total . <br /> TOTAL $ "---oo $ rr Charges <br /> ->< <br /> CREDIT $ �J� $ Less <br /> _ Credits �• <br /> DATE BILLING SUBMITTED:� 9� BY: -K` BALANCE DUE $ ,SZ <br /> * Use for site as sment proposals, wor p a etc. <br /> **Include travel t ine for field services <br />