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BjT,,rTAte RECORD FORM <br /> DBA <br /> SITUS ADDRESS <br /> PROGRAM: SWEEPS# : Z <br /> BILL TO: COMP. # : T. Z <br /> NAME: 5�4 C--7-c 0 1 C co, <br /> x 'P.O. 502S <br /> ADDRESS : <br /> CITY:gWeg�,I- STATE: (f14 Z I P <br /> TITLE OF SUBMITTAL N11\ <br /> OR DESCRIPTION OF SERVICE:— n�°oj-j� <br /> *DATE RECEIVED: *DATE OF SUBMITTAL: <br /> INITIL CK#/ ADDIL CK#/ TOTAL HRS (use 1/4hr increment's) SANITARIAN <br /> DATE FEE PD CASH FEES CASH OR <br /> PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CijERK <br /> HOLIDAYS <br /> 2-tNem?o <br /> �31 0 iq R-Is <br /> TOTAL HRS j HRS HRS <br /> $3,5 <br /> ,/HR @ 52. 50/HR @ $70/HR Total <br /> Charges <br /> TOTAL $ -00 $ <br /> CREDIT Az— /5� Less <br /> Credits <br /> DATE BILLING SUBMITTED: 0 <br /> F5 BY: BALANCE DUE <br /> Use for site assessment proposals, workDla e c. <br /> "Include travel a e for field services <br />