Laserfiche WebLink
BILLING RECORD FORM <br />DBA: <br />SITUS ADDRESS: <br />PROGRAM: <br />BILL TO: <br />NAME: TSS e n <br />ADDRESS: Z730 Qp <br />C I T Y <br />TITLE OF SUBMITTAL <br />OR DESCRIPTION OF SERVICE: <br />*DATE RECEIVED: <br />SWEEPS#: 173 <br />COMP .#: /Ho <br />2 <br />4,2C <br />ST TE: ZIP: 9, <br />*DATE OF SURMTTTAr.? <br />DATE <br />INIT'L <br />FEE PD <br />CK#/ <br />CASH <br />ADDIL <br />FEES <br />PD. <br />CKV <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 />$ 7o 0 0 <br />$ 0 <br />HRS <br />HRS <br />HRS <br />@ $3,5/HR <br />@ 52.50/HR <br />@ $70/HR <br />- $ Charges <br />Less <br />Credits <br />BALANCE DUE $ -70,00 <br />TOTAL 1:>< <br />CREDIT <br />$ <br />$ <br />[DATE BILLING SUBMITTED: BY:- <br />* flora f 11 V- e ; !-n 9c - -1 ----4 <br />"Include travel e for field services <br />I <br />CD <br />