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STATE OF CALIFORNIA <br /> AGENCY BILLING CONTRACT/DELEGATION PUR )NITACTMELEW NO PAGE OF PAGE <br /> CHA,40ORDER 2 <br /> STD. 65(REV. 4`92D(CONTINUOUS) Lt—L <br /> 'JI'_i" I :. it I I::A'iZWH r�:j W.) I 1::J.lIAJA I OATE:gu.Nrr.., truly,injiI <br /> S B <br /> H <br /> I -�GRE:1: N 'TRI: El <br /> 1 2000 E:.Vf..*r S <br /> 20' <br /> P L <br /> CR0ftNT0 ('A 9`581`.J---,-5896 L I: ACRAMEN'TT 958:1.5 AGENCY ORDER NUMBER <br /> .1 ... 93 ... <br /> T AMM 1STRATIME 9 F'RVI'C'E'E, T 2 <br /> VENDOR! THIS NUMBER MUST BE <br /> SHOWN ON INVOICE. <br /> COMPLETE ONLY <br /> colm I Y (.)I - C;(.)N J-o tvilmrN —1 WHEN TO BE USED AS VENDOR'S INVOICE <br /> TO CIFT'I'CE, 0I::' EMI:RGENCY VENDOR'S INVOICE <br /> FIRM 1: 1 hereby certify that this is a true NiLs� <br /> WOM 6:1.0, DER <br /> ADDRESS and just bill and payment has not <br /> (Type or 222 W1:..'BE:.R AV1:..*N(.Ji::.' been received. <br /> Print '3'F(: CKT0N, ("A 95202 VENDOR'S SIGNATURE <br /> Legibly) 00. <br /> VENDOR NUMBER LLd 13 0 k S/B TITLE(DINNER.Van., CLERK. ETC.) <br /> 1 4. Vendor's Federal Employer Identification Number <br /> NOTICE 1 1. Show the Agency order number and Contract/ is racluired. <br /> Delegation number an your invoice. <br /> TO 2 Show cash discounts offered an your invoice. 5. Submit original receipted expense bills if your VENDORS TAXPAYER I.D.NUMBER(FEIN, <br /> MERCHANT 3. Submit invoice in triplicate.If not on printed bill invoice includes prepaid transportation charges. <br /> head,verwor please sign invoice. All shipments shall be FOB. destination unless <br /> otherwise stated on this order. <br /> DATEIVVANTIEW)CSHIP VIA <br /> . .1) inw-mis .,,o T7( ys' <br /> ITEM NO. QUANTITY UNIT COMMODITY CODE DESCRIPTION UNIT PRICE EXTENSION <br /> K.,magement 5( ij() <br /> F'rocii, imn (FIMMP) latc.-i Tem---s For <br /> f--r,)�EN N is). <br /> Citta W:it.f?I"I"IYrtCa.l'7'la'Y Control <br /> F'vogrzxin Account, 0 @146 <br /> COUNTY <br /> OFFlCE OF EMERGEIZIIRVICES <br /> DIED,,,t.J. EI fl I <br /> SALES TAX <br /> O A r.1f.j")F'ATEGORY(CODE AN.ITTLE) <br /> FILE 191PTI AL 1-50 <br /> H g' <br /> A TOTAL <br /> N nrs�nM: TER <br /> E S .30....00:j....."t5l.6 'jAR� OlEtr <br /> J,.)OF EXPENDITURE(CODE AND TITLE) <br /> In O.E. 0 EQ. <br /> CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER UNENCUMBERED REMAINDER AFTER <br /> I HEREBY CERTIFY,On My own permnal knowledge that this.,it.,for the pi,irchus, POSTING THIS ORDER TO ALLOTMENT <br /> of the items Xpaififed Idsmis B Issued in accordance with the procedure proscribed by law of LEDGER <br /> gooroming the purchase of such Item, for the State of Calljonaid; that all such legulAX1U.TMKNT <br /> requirements ham been fully complied with. INCREASING ENCUMBRANCES <br /> (916)26,`S 0870 <br /> ADJUSYRFNT <br /> SIGNATU 9 DECREASING ENCUMBRANCES <br /> CERTIFIED CORRECT(SIGNATURE) <br /> biSAL3,17TION: Copy 1 Ve Copy 2/Procurement; Copy 3 - Packing Slip; Co 4-7 Miscellaneous(Agency) <br />