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STATE OF CALIFORNIA <br /> CONTRACT/DELEG.ATION PURCHA�RDER CODE AGENCY BILLING CONTRACT/Di No. PAGE OF PACE <br /> STD.89)REV. tr82)(CONTINUOUS) y NC eI O t 0 2 <br /> S <br /> H , B <br /> �.:I' I.N'TEI VI Y.X,T'IK) <br /> I <br /> P <br /> L <br /> T AGENCY ORDER NUMBER <br /> O C'Z)99--.-,n,f,(d <br /> VENDOR: THIS NUMBER MUST BE <br /> SHOWN ON INVOICE. <br /> COMPLETE ONLY <br /> WHEN TO BE USED AS VENDOR'S INVOICE <br /> TO <br /> FIRM <br /> hereby Certify that this is a true NUM ERS INVOICE <br /> ADDRESS and just bill and payment has not <br /> (Type or been received. <br /> Legibly)LVENDOR'S SIGNATURE <br /> Legi <br /> LJ TITLE(OWNER,MGP..CLERp.ETC.) <br /> VENDOR NUMBER L I I I 8/B LlETM <br /> t. Show the Agency ortler number entl Contract/ C. Vandor's Federal Employer Identification Number <br /> NOTICE Delegation number on your invoice. is required. <br /> TO 2. Show cash discounts offered on yourinvoice. 5. Submit original raceipted expense bills it your VENDOR'S TAXPAYER I.D. NUMBER(FEIN) <br /> MERCHANT 3. Submit invoice in triplicate.If not on printed bill invoice includes prepaid transportation chargee. <br /> head,vendor please sign invoice. S.All shipments shell be F.O.B. destination unless <br /> otherwise stated on this order. <br /> DATE WANTED SNIP VIA <br /> TERMS <br /> I <br /> --- --- ----TIi —•-•• ....mmuunr CO DESCRIPTION UNIT PRICE <br /> EXTENSION <br /> OEi 24!5 I"(. !'i(.',L_D y (.(.NAV 1.0 i y .,T <br /> NO F"C)FiF::F.CiiN--MAS)I'i: Ei:(EIt.J7a"MEi:N'T'y MATEi:R:I:AI._5iy OR ;.3U 'Fh(..:I: i:;S <br /> w-IC)C_EC OR IN F'AR'T BY F C RCIIE::D L..ABOF:n CONVICT L F)1?C)R , CNS <br /> ca:JEEaI''T':I:Nt:) A I'UI'iC. 11Ale: f:)RDEi:Fiy 'CFI!:i: Cc)A1T'I"{Ai:;"fC)R ACiFiIE t::ii TOf::(:1MI'...Y <br /> O <br /> x. w:E'T'1I D:f.�iAl{II_.:C'T'7:Ei:Ei ACI <br /> C:)N'TTRALICR Af:S UF'E_£i T'1 IIS:, ;3'T'A'T'I::: 'THAT S'T <br /> "0M1'-"1.-' E-13 !J :'TIT THE. <br /> MIii:Fi:Tf::AN3 W:C'T'Fi T 7:f'rASit:F.L..l:Y7:E:r ACT (ADA) OF :1.990.. F11U.-I <br /> F' (:nI:I:Ti:C'T'f3 D:CSCRIM:I:NATTON ON THE: BAS)TC) OF. I):f.SA,;t:Cl..:f.'TY., AS !:.1 ::1._t.. <br /> -53 Al...L.. AI='!'L..:CC:AT;tL.J::: RE.'GUI...A'T':CONf3 AND £i <br /> T::) 'THE.' ADA., (42 U.S .C„ -1.21.01. E:T- 13EEG4„ ) <br /> � I — <br /> ,flT <br /> FOB <br /> t OFF) c ENCYSERVICES <br /> _. <br /> C qG PROGRAM CATEGORY(CODE AND TTLE) FVND TITLE (OPTIONAL USE) <br /> H q <br /> A I TOTAL I <br /> R IN ITEM - CHAPTER <br /> G 9 STATUTE FISCAL YEAR OBJECT OF EXPENDITURE(coDE AND TITLE) <br /> E T I <br /> I ❑ O.E. ❑ EO. <br /> CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER <br /> UNENCUMBERED REMAINDER AFTER <br /> !HEREBY CERTIFY, On my Coin personal knowledge that this order for the purchasePOSTING THIS ORDER TO ALLOTMENT <br /> of the items specified Show is Issued in accordance ankh the procedure prescribed by law EXPENDITURE LEDGER <br /> governing the purchase of such items for the State o/ California; that al/ such legal <br /> requirements have been fully Complied with. ADJUSTMENT <br /> TITLE INCREASING ENCUMBRANCES <br /> J� J ADJUSTMENT <br /> 91GNATVRE DECpEA31N6 ENCUMBpgNCES <br /> CERTIFIED CORRECT(SIGNATURE) <br /> DISTRIBUTION: Copy 1 - VO Copy 2 - Procurement; Copy 3 - Packing Slip; C 4-7 - Miscellaneous(Agency) <br />