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'SATE OF CALIFORNIA AGENCY BRLNG CONTRACT/GE. /ON NO. 'PAGE OFI PAGE 1 <br /> CONTRACT/DELEGATION PURCHCA3e /yO�RD� CODE 1170501 ggd170V5' <br /> STO 6S IREv.}911 VE$ 1627.W <br /> DATE axaRrN.WY.Yi11RI <br /> S e I I I I 06-03-a4 <br /> H DEM VOCATIONAL INSTITUTION L DEVOCATIONAL INSTITUTION <br /> L PO BOX 378001 AGENCY ORDER NUMBER <br /> P 23500 KASSON ROAD <br /> T 1 MILE S. HWY. 205 (BUSINESS) TTRACY, CA 95378 31860-45 <br /> D D TRACY, CA 95376 VENDOR: THIS NUMBER MUST BE <br /> _ SHOWN ON INVOICE. <br /> •cry n�w� <br /> r COMPLETE ONLY <br /> (209) 468-0340 WHEN TO BE USED AS VENDOR'S INVOICE <br /> VENDOR'S INVOICE <br /> TO SAN JOAQUIIN COUNTY PUBLIC HEALTH SERVICES I hereby certify that this is a trae NUMBER <br /> FIRM and just bill and payment has riot <br /> ADDRESS ENVIRONMENTAL HEALTH DIVISION been received. <br /> (Type or P.O. BOX 2009 VENDOR'S SIGNATURE <br /> Print STOCKTON, CA. 95201 <br /> Legibly) Illy <br /> J TITLE(OWNER. MOR..CIERR.ETD.) <br /> D <br /> VENOR NLVLMER I 6/S LJ ETN LJ <br /> I f. Show the Agency order number and Contractl 4.Vendor's Federal Employer Identification Number <br /> is required. VENDOR'S TAXPAYER 1.0. NUMBER(FEIN) <br /> NOTICE I Delegation number on your invoice. 6. Submit original receipletl expense bills if your <br /> TO I 2. Show cash discount.offered on your invoice. invoice includes prepaid transportation chargee. <br /> MERCHANT 1 3. Submit invoice in triplicate-If not on printed bill 6. All shipments shall be F.O.B. destination unless <br /> head,vendor please sign invoice. otherwise stated on this order. <br /> TERMS <br /> DATE WANTED SHIP VIA <br /> UNIT PRICE EXTENSION <br /> ITEM NO. QUANTITY UNIT COMMODITY CODE <br /> DESCRIPTION <br /> 01 PERMIT FEEeS UNDER GROUND TANK FEE' 510.00 510.00 <br /> PAID BY REV—FUND CR �j`y <br /> Foe <br /> BALER TAX <br /> C A PROGRAM CATEGORY(CODE AND TITLE) FUND TITLE (OPTIONAL USE, I <br /> H G REEVFS,4202 TOTAL I 510.00 <br /> A A np G—AM G6 <br /> R N ITEM ��"" CHAPTER STATUTE FISCAL YEAR 0;;T EXPENDITURE AND <br /> E T ]pJ10w+5—OO \ I ❑ O.G ❑ EO. <br /> CFR71FICATION AND APPROVAL OF EXECUTIVE OFFICER UNENCUMBERED REMNNDaa AFTER <br /> POSTING TNI.ORDER TO ALLOTMENT <br /> I HERERI' CFR TIFY, OR my oum personal knowledge that this order for the purchase EXPENDITURE LEDGER 1 <br /> 000 <br /> of the Rems specified share is issued to accordance ruith the pracedme prescribed by lam <br /> governing the purchase of such items for the State of California: that all such legal ADJUSTMENT <br /> requi rams.is haw'been fully complied n ith. INCREASING ENCUMBRANCES 333536 <br /> TITLE <br /> PROCUREMENT & SERVICES OFFICER II AOREAS <br /> ECREASENT 22050 <br /> OING ENCUMBRANCES <br /> SIGNATURE ^ CERTIFIED CORRECT(SIGNATURE) <br /> D.R. CLA <br /> DISTRIBUTION: Copy 1 - V*AmE; Copy 2 - Procurement; Copy 3 - Packing Slip; (yrls 4-7 - Miscellaneous(Agency) <br />