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-BILLING RECORD FORM <br /> DBA: &-1 e1,1 i <br /> S Y TUS ,ADDRESS:- .73 7 �/,2�> �' k <br /> PROGRAM:_ <br /> BILL T0: ^� <br /> SW�' EEPS# :�z <br /> COMP. # : <br /> - TI-7177 <br /> NAME: G� <br /> ADDRESS : <br /> CITY• STATE: <br /> .— ZIP <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: � G" <br /> *DATE RECEIVED: *DAT OF SUBMITTAL: <br /> INIT°L K# ADD°L CK#/ TOTAL HRS (use 1/4hr increments ) SANITARIAN <br /> DATE FEE PD CASH FEES CASH OR <br /> po� PD. WEEKDAYS WEEKNIGHTS WEEKEND/ CLERK <br /> 3� ��� HOLIDAYS <br /> io <br /> =3 Y <br /> to °" V . <br /> 11-746 <br /> ham. <br /> TOTAL $ �� $ �✓'" HRS HRS HRS <br /> =:: @ $3,5/HR @ 52 . 50/HR @ $70/HR Total <br /> TOTAL <br /> Charges <br /> CREDIT $ $ $ Less ,`66 <br />�-` Credits <br /> DATE BILLING SUBMITTED: BY:— BALANCE DUE $ -2 4O0„ <br /> * Use for site assessment proposa s, wor p ails, etc—. <br /> •J '" <br /> **Include travel tie for field services <br />