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BILLING RECORD FORM <br />DBA, <br />SITUS ADDRESS: A3A ee ZOg7 a <br />S�o C r4-z� <br />PROGRAM: S, SWEEPS #.- <br />COMP .#: <br />BILL TO: <br />NAME: Ro hvt4 40-t- a�� <br />ADDRESS: <br />CITY: STATE: ZIP: <br />TITLE OF SUBMITTAL <br />OR DESCRIPTION OF SERVICE: <br />*DATE RECEIVED: <br />*DATE OF SUBMITTAL: <br />DATE <br />INITIL CK#/ <br />FEE PD 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 I$ <br />$ <br />HRS <br />HRS <br />HRS <br />. ...... . . . . . <br />@ $35/HR <br />@ 52.50/HR <br />@ $70/HR <br />Total <br />p-, <br />Charge <br />TOTAL <br />CREDIT <br />$ <br />$ <br />$ <br />$ <br />Less` 0 <br />Credits ?® <br />DATE BILLING SUBMITTED: BY: <br />BALANCE DUE <br />$ <br />- U5t-' LUZ 5Lt_U a5ZjU:j5111U11L PLUPUZ5a.L61 WULAP.Lallb, t_-UU. <br />**Include travel time for field services <br />