Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Danielle Byers
1415 Park St
Marlin, TX 76661
POLICY# 5672716F2043

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-1410 09/08/2023 09/11/2023 On Receipt Sam Bass Fire Department

Product
Price
Qty
Amount
  1. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1
    $500.00
  3. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1
    $250.00
  4. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  5. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  6. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  9. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 3807 FM 1431- Round Rock, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,630.00
Total Due $1,630.00


Updated
September 11, 2023 @ 11:16 am

Invoice updated by Geoffrey.

Status Update
September 11, 2023 @ 11:16 am

Status changed: Draft to Pending.

Viewed
March 20, 2024 @ 6:32 pm

Invoice viewed by 66.249.72.6 for the first time.