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STATE OF CALIFORNIA <br /> AGENCY BILLING CONTRACT/DEUEGAOINO. PAGE OF PAGE <br /> CGNTRACT/DELEGATION PURCHASORDER CODE <br /> 1) <br /> -.11L 0 1 S -1 I <br /> STD. 95(REV.492)(CONTINUOUS) <br /> S 0I.J."I k0t)*f 1 Nti & WA I LRWAYS B 014'.PT. BOATINO & WATFRWAYS) <br /> H E I RE;E 1 77`1`77,77'1 <br /> 1 2000 EVERONEEN SIREXT L 2000 F.MER <br /> IF L AGENCY ORDER NUMBER <br /> SACIRAME-W109 GA 915015-3696 SACRAMF."N'ro, FSA 9�isv�i <br /> T ADMINT.STRATIVF. SERVICES T (:11:w 4WV., <br /> 0 BsOO A.A. --- 5nOO P.M. O VENDOR: THIS NUMBER MUST BE <br /> SHOWN ON INVOICE. <br /> COMPLETE ONLY <br /> F- WHEN TO BE USED AS VENDOR'S INVOICE <br /> VENDORS INVOICE <br /> TO Office (:IF r".fileriglency Svrvicea I hereby certify that this is a true NUMBER <br /> FIRM and just bill and payment has not <br /> ADDRESS 222 N". Webeir Avenitte been received. <br /> (Type or Stockton, CA 95202 <br /> Print VENDOR'S SIGNATURE <br /> Legibly) Ill. <br /> Lt I TITLE (OWNAWtEllitax.unc.) <br /> VENDOR NUMBER a/. AR 2, <br /> 1 1. Show the Agency order number and Contract/ 4. Vendor's Federal Employer Identification Number <br /> NOTICE I is required. <br /> Delegation number on your invoice. 5. Submit original receipted expense bills if your VENDOR'S TAXPAWSPO <br /> TO 2. Show cash discounts offered an your invoice. <br /> MERCHANT ; invoice includes prepaid transportation charges. W, <br /> 3. Submit invoice in triplicate.It not on printed bill 6. All Shipments shall be F.O.B. diattimition unless <br /> head,vendor please sign invoice. otherwise stated on this order. <br /> o 3^/,"r�uo 1. SHIP VIA "So DAYS <br /> ITEM NO, QUANTITY UNIT COMMODITY CODE DESCRIPTION UNIT PRICE EXTENSION <br /> I.)N)J. I-VAMP Annual 1: vo 405.00 4 05.0 0 <br /> DPPft2 0 FvAid FTIR2 Facilitiesi S>urner 0.00 <br /> SALES TAX <br /> C A IN 'TLE (YPTIONAL USE) $405.00 <br /> G 'y k1-RT :A-, J 0�,.;;00 TCYTAL <br /> VITA <br /> H <br /> A A <br /> N' _.R" STATUTE FISCAL YEAR OBJECT OF EXPENDITURE(CODE AND TTrU) <br /> )7 <br /> ("77 R� ; <br /> N ITEM CHAPTER <br /> -'e --.Ooj' Ll O.E. El EQ. <br /> E TS '38() 1'6 <br /> CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER UNENCUMBERED REMAINDER AIER <br /> V0ISTING T.I.ORDER TO ALLOTMENTI HEREBY CERTIFY, OR my own personal knowledge that flits order for the purchase <br /> EXPENDITURE LEDGER <br /> of the item specified abome is issued in accordance with the procedure preirceived by raw <br /> goorming the purchase of such item for the State of California; that all such legal ADJUSTMENT <br /> requirements have been fully consphad with. INCREASING ENCUMBRANCES <br /> IS <br /> T <br /> 17iLsirw,ss Services Officer- (91.6)'263,-0070 <br /> ADJUSTMENT <br /> DECREASING ENCUMBRANCES <br /> SIGNATURE, CERTIFIED CORRECT(SIGNATURE) <br /> 10-Akoa, �) -,- - I Do. <br /> DISTRIBUTION; Copy I - Vendor; Copy 2 - Procurement; Copy 3 - Packing Slip; Copies 4-7 Miscellaneous(Agency) <br />