Bill To:


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

Services Rendered To:


Jeffery Cook
148 Pleasant Run
Azle, TX 76020
POLICY# 4615337-B24-431

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-206-22-556-B 05/13/2022 12/12/2023 On Receipt Briar-Reno Fire Department

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

    $400.00
    1
    $400.00
  2. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  6. 322 Turn Out Gear / PPE (Per FireFighter)

    $250.00
    2
    $500.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 1066 E Reno Rd- Azle, TX

    Ordinance Info: Briar Reno Cost Recovery Ordinance

Subtotal $1,283.00
Total Due $1,283.00


Updated
December 12, 2023 @ 12:48 pm

Invoice updated by Geoffrey.