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[]
[null,"UTAH COUNTY AMBULANCE  BILLING FORM"]
[null,"Billing Agency Name",null,null,null,null,null,"FDID#"]
[null,"Incident Location:",null,null,null,null,null,"UFIRS INC#"]
[null,"City Incident #",null,null,null,null,"Incident Date:"]
[null,"County Incident #",null,null,null,null,"Prepared by:                                "]
["EQUIPMENT TIME LOG",null,null,null,null,null,"UC Contract #:"]
["The personal data collected on this form is classified as a public record and may be made available to the public as provided by Utah Code 63G-2-201."]
["Apparatus Radio* Call # and Class #","Alarm","Enroute","Arrived","Completed","Available","TOTAL TIME","X $Rate"," Total cost"]
[null,null,null,null,null,null,{"$f":"(F10-B10+(F10<B10))*24","v":0},null,{"$f":"(G10*H10)","v":0}]
[null,null,null,null,null,null,{"$f":"(F11-B11+(F11<B11))*24","v":0},null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
["Mileage*","Miles To",null,null,null,"From","Total Miles"]
[null,null,null,null,null,null,{"$f":"SUM(F18+B18)","v":0},null,0]
[null,null,null,null,null,null,{"$f":"SUM(F19+B19)","v":0},null,0]
[null,null,null,null,null,null,{"$f":"SUM(F20+B20)","v":0},null,{"$f":"(G20*H20)","v":0}]
[null,null,null,null,null,null,"Total Equipment Cost",null,{"$f":"SUM(I10:I20)","v":0}]
[]
[]
[]
[]
["***Rates for Federally Owned Equipment (FEPP) will be billed according to the State Federal Excess Rates and do not include personnel cost. "]
["PERSONNEL REQUIRED                                        "]
["Name & Position/ Certification*","Alarm","Enroute","Arrived","Completed","Available",null,"X $Rate*"," Total cost"]
[null,null,null,null,null,null,{"$f":"(F29-B29+(F29<B29))*24","v":0},null,{"$f":"G29*H29","v":0}]
[null,null,null,null,null,null,{"$f":"(F30-B30+(F30<B30))*24","v":0},null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,{"$f":"G35*H35","v":0}]
[null,null,null,null,null,null,0,null,0]
[null,null,null,null,null,null,0,null,{"$f":"G37*H37","v":0}]
[null,null,null,null,null,null,0,null,{"$f":"G38*H38","v":0}]
[null,null,null,null,null,null,0,null,{"$f":"G39*H39","v":0}]
[null,null,null,null,null,null,"Total Personnel",null,{"$f":"SUM(I29:I39)","v":0}]
[null,null,null,null,null,"Total Equipment:",null,null,{"$f":"SUM(I21)","v":0}]
[null,null,null,null,null,"Total Personnel:",null,null,{"$f":"SUM(I40)","v":0}]
[null,null,null,null,null,"TOTAL BILLING:",null,null,{"$f":"SUM(I41:I42)","v":0}]
["Please Mark All That Apply"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"Instructions to Submit:\nSave to personal files. Attach the excel file(s) to an email. Send email to: ucfm@utahcounty.gov "]
[]
["REVIEWED / PAYMENT APPROVAL"]
[null,null,null,null,null,"Reports must be submitted within 30 days*"]
[null,null,null,null,null,"Questions call:801-851-8348 "]
[null,null,null,null,null,"CHARGES REVIEWED PRIOR TO PAYMENT"]
[null,"UC Fire Marshal"]