Bill To:


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

Services Rendered To:


Misty Simpson
8040 Vista Del Sol
Azle, Texas 76020
Policy # 122-2046-C01-43Q


Product
Price
Qty
Amount
  1. 104 Tanker Response (Per Hour)

    $300.00
    1
    $300.00
  2. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  3. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  4. 407 Patient Care / Evaluation (Per Patient)

    $50.00
    2
    $100.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 12479 Lake Forest Drive - Azle, Texas

    Ordinance Info: Briar Reno Fire Department - Bylaws Authorization for Cost Recovery

Subtotal $750.00
Total Due $750.00
Updated
December 9, 2020 @ 1:18 pm

Invoice updated by Geoffrey.

Status Update
December 9, 2020 @ 1:18 pm

Status changed: Draft to Pending.

Viewed
October 25, 2022 @ 2:35 am

Invoice viewed by 64.124.8.53 for the first time.