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BILLING RECORD FORM <br /> DBA Sh P�I <br /> SITUS ADDRESS: � � <br /> PROGRAM: SWEEPS# : (0 ?,4 <br /> BILL T0: <br /> COMP. # <br /> NAME: lC_i 1`Iej:Z, <br /> ADDRESS : c;Z <br /> CITY: STATE: ZIP: "(PGi I <br /> TITLE OF SUBMITTAL <br /> OR DESCRIPTION OF SERVICE: [it <br /> *DATE RECEIVED: *DATE OF SUBMITTXL: <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 /> T� 1H P <br /> V• <br /> TOTAL $ $ HRS HRS HRS <br /> @ $3,5/HR @ 52. 50/HR @ $70/HR Total a 6 - <br /> TOTALy' <br /> Charges <br /> CREDIT $ L$ � ' $ $ Less . <br />�-' Credits =, <br /> DATE BILLING SUBMITTED: BY: BALANCE DUE $ ,M <br /> * Use for site assessment proposals, workplan <br /> **Include travel for field services <br />