Bill To:


Jose Rivera Ontero
406 Prairie Lane
Azle, TX 76020

Services Rendered To:


Jose Rivera Ontero
406 Prairie Lane
Azle, TX 76020
Policy # VCVGXH


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

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

    $300.00
    1
    $300.00
  2. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  3. 309 Power Tool (# Used)

    $50.00
    1
    $50.00
  4. 202 Oil Absorbent Sheet (# Used)

    $2.50
    1
    $2.50

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 11700 FM 730 North - Azle, Texas

Subtotal $382.50
Total Due $382.50


Updated
October 24, 2021 @ 1:33 pm

Invoice updated by Geoffrey.

Status Update
October 24, 2021 @ 1:33 pm

Status changed: Draft to Pending.

Updated
October 24, 2021 @ 2:02 pm

Invoice updated by Geoffrey.

Updated
December 30, 2021 @ 6:38 pm

Invoice updated by Geoffrey.