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..o <br /> STATE OF CALIFORNIA <br /> AGENCY BILLING LOCAT �N CONTRACT/DELEGATION NO. PAGE OF PAGE <br /> CONTRACT/DELEGATION PURCHASE ORDER CODE <br /> STD es 16/821 1 <br /> VE# 512648-01 1117 ,01510 101110 I l l l l l l l l l 0 1 0 1 <br /> E e Dwr <br /> N IMONTM,DwY, Yewq <br /> 1 L 10, 310 51 8 6� <br /> v DEUEL VOCATIONAL INSTITUTION L DEUEL VOCATIONAL INSTITUTION AGENCY MORK NUMBEa <br /> T 23500 KASSON RD. T P. 0. BOX 400 <br /> O 1 MILE SOUTH HIWAY 205 BUSINESS D Tracy, Calif. 95378-0400 56-6285 <br /> 00 TRACY, CA ► VENDOR: This Number MUST <br /> Be Shown on Invoice. <br /> I� � r <br /> COMPLETE ONLY <br /> BE USED AS VENDOR'S INVOICE <br /> TO VENOOa . INVOICE <br /> FIRM rtify that this is NUMBER <br /> ADDRESS San Joaquin Local Health District lust bill and pay. <br /> (Type or 1601 E. Hazelton Ave. ot been recelved. <br /> Prinr Lteelbly) P. 0• Box 2009 a NATURE <br /> LStockton, CA 95201R M <br /> 6NDOw NUMHHR L I SZE u <br /> 1 1. Show the Agency order number and contract/Delegation num- <br /> I4. Submit originalexpanse bilis If your Invoice Includes <br /> NOTICE I Der on your invoice. Prepaid transportationanon charges. <br /> TO 2. Show cash discounts offered on your Invoice. 5. All shipments shall be F.O.B. destination. unless otherwise <br /> MERCHANT I 3. Submit Invoice In triplicate. If not On printed bill head, vendor Stated OD this Older. <br /> Please sign Invoice. <br /> DATE WANTED DMIP VIA <br /> ASAP TERMS <br /> QUANTITY UNIT STOCK ITEM NUMBER DESCRIPTION UNIT PRICE .TENSION <br /> 1 ea Permit to Operate Under Ground Fuel Tank 150.00 150.00 <br /> 7 ea 11 "11"" 11 11 11 11 1I 50.00 350.00 <br /> 8 ea Surcharge on Tanks 56.00 448.00 <br /> REVOLVING FUND CHECK # <br /> POB pnn <br /> SALES TAE I 8rtH7C�� <br /> q PROGRAM CATEGORY(CODE AND TITLE) FUND TITLE .-/ (OPTIONAL USE) <br /> C 7aryy <br /> H N RECURRING MAINT. <br /> A <br /> CRUM II <br /> TOTAL I <br /> R N ITEM GRAFTER STATUTIf ISCAL YEAR I OBJECT OF EXPENDITURE(CODE AND TITLE) <br /> E r 85/86 6/30/86 E21S6285-00 <br /> CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER ..............MAI.... <br /> I HEREBY CERTIFY, On my own personal knowledge that this order for .c T.. I.M..IM.ogD.q 1000 <br /> ALLOTM..T.;reNDITYR.LeD4.R <br /> the purchase o/ the items sp ifled abo k issu in accordance with the <br /> Procedure prescribed by law r Ing th rch -(such items for the State ADJUSTMENT 323346 <br /> o/ California; that all such g quire a ha en fully compiled with. Iw.....I.. ....M....... <br /> slarywru RH <br /> 10 ADJY.TM.NT 2x,050 <br /> K. A. Gorham D.Cw.A.I.. ....M......e L <br /> TITLE ------CERTIFIED CORRECT STONATY;. <br /> PROCUREMENT & SERVICES OFFICER <br /> DISTRIBUTION: Copy I - Vendor;Copy 2-Procurement;Copy 3-Packing Slip;Copies 4-7-Miscellaneous (Agency) <br /> AV <br />