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DEPARTMENT <br /> QC.�> �t�Y' I <br /> STATE F DEPARTRANPPORTATION v li <br /> CONFIRNfINGARVICE CONTRACT DISTRICT CON SHEET CONFIRMING SERVICE CONTRACT NO. <br /> CQNTRgCTOR(PLEASE PRINT) 10 — 1 OF_1 100649 <br /> PHONE <br /> DATE <br /> ADDRESS 1 <br /> - HAZELTO(1 N DATE SERVICE BEGAN DATE SERVICE COMPLETED <br /> , ;5201 1/1/89 <br /> INSTRUCTIONS TO CONTRACTOR: Please fill in the followin 1;t Priv <br /> Discount and Sales Tax, Invoice Numb er(if invoicin separately), Si (at:TAINre YELLOW COPY FOR YOUR FILE) Unit Price, Extension and Total, <br /> I hereby certify that this is a true and just bill and payment hasnot been TITLE(FRES,OWNER,MGR.,ETC) <br /> CONTRACTOR <br /> CONTRACTORS LICENSE NO. <br /> CONTRACTOR SIGNATURE: <br /> INDICATE IF VOU WILL INVOICE SEPARATELY <br /> IF INVOICING SEPARATELY,MAIL - <br /> ❑ NO ❑ 1'ES INVOICE NO. SEE ATTACHED COPIES TO: - - <br /> The provisions on the reverse side hereof constitute a part of this contract. <br /> The contractor agrees to furnish the service or rental as stated herein to <br /> and accept as full Compensation therefor the prices name of'Fr <br /> and agrees to receive <br /> PERMIT FEES FOR UNDERGROUND STORAGE TANK LOCATED AT THE LODI MAINTENANCE FACILITY. <br /> TOTAL AMOUNT AUTHORIZED UNDER THIS CONTRACT------------------------ <br /> '--------$ZU0.00 <br /> PUY <br /> U <br /> JAN 301989 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> SMALL BUS. U ETHNIC CODE LI i <br /> f. <br /> TERMS: DISCOUNT_ % DAYS <br /> The California Department of TraTAL $200.00 <br /> nsportation hereby agrees to the terms as above set forth and hereby0agrees to pay same. <br /> The original of this CONFIRM/NG SERV/CE CONTRACT willservese eas your IN0OVO/CE to the California Department of Transportation <br /> (unless you otherwise indicated above), and is now in process of payment. <br /> COMPANY NAME AND WHO CONTACTED <br /> BID <br /> COMPANY NAME AND WHO CONTACTED <br /> BID <br /> DISTRICT CERTIFICATION AND APPROVAL <br /> l the quanrm tity <br /> theaboveservices Were-reoetved,byMe State of Galifomia• APPROVED _ <br /> in the quantity ander u�altt-fir _ -- - ---'-'-' <br /> By Asst an o a ts� Ofce <br /> SOURCE CHARGE E UTH, SPECIAL DESIGNATION ---- —_ -- __ <br /> ITEM <br /> GEN.LEO ue-Acci x W PARSUB-JOe ENCUMBRANCE 2-20 <br /> DIST. UNIT DIST. UNIT w R/ PARCELL N NO: OBJECT AMOUNT _ FISCAL <br /> WORK ORDER NO. T LOCATION _ DEBIT OR CREDIT YEAR DOCUMENT CHAPTER <br /> eRIDDE No..Eic. NUMBER <br /> I <br /> 1D6E 5T400 707 $200.00 89 STATUTES FISCAL YEAR <br /> DAS-OBM-1 414(REV 12/83) �RIBUTION: ORIGINAL(WHITE)-E)-DISTRICT 3RD COPY(YELLOW)-CONTRACTOR <br /> 2ND Copy 3RD OFFICE OF BUS.MGM* 4TH-8TH COPIES(WHITE) <br /> -DISTRICT <br />