Bill To:


JUSTIN OLSEN
3300 Fallmeadow St., Apt. 2109A
Denton, TX 86207

Services Rendered To:


Justin Olson
1408 Gilley Trail
Azle, TX 76020
Driver: Sam Sons
Policy # 22063

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-440-2020-875 09/29/2020 01/12/2021 On Receipt Briar-Reno Fire Department

*** THIS HAS BEEN SUBMITTED TO YOUR INSURANCE COMPANY AND IGNORED. THIS IS NOW YOUR RESPONSIBILITY. ***

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

    $300.00
    1
    $300.00
  2. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  3. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  4. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  6. 404 Scene Lighting (Per Hour)

    $75.00
    1
    $75.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 326 Safety Fest (# Used)

    $2.50
    3
    $7.50
  9. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00
  10. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  11. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Intersection of Long Avenue and Gilley Trail - Pelican Bay, Texas

    Ordinance Info: Briar Reno Cost Recovery Amendment

Subtotal $1,269.50
Total Due $1,269.50


Updated
January 11, 2021 @ 5:02 pm

Invoice updated by Geoffrey.

Status Update
January 11, 2021 @ 5:02 pm

Status changed: Draft to Pending.

Updated
October 19, 2021 @ 3:24 pm

Invoice updated by Geoffrey.

Updated
June 2, 2022 @ 5:08 pm

Invoice updated by Karen Smith.

Viewed
June 2, 2022 @ 5:08 pm

Invoice viewed by Karen Smith (KarenS) for the first time.

Updated
June 2, 2022 @ 5:09 pm

Invoice updated by Karen Smith.

Updated
August 3, 2022 @ 6:22 pm

Invoice updated by Karen Smith.

Viewed
August 3, 2022 @ 6:22 pm

Invoice viewed by Karen Meder - Smith (KarenS) for the first time.