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• . Department of Developmental Services <br /> SuL of Caliipmia—Health and Welfare Agency <br /> SERVICE ORDER r <br /> Ds 1t6tJ-st (11/91) a Stockton Developmental Center <br /> � <br /> Fiscal Office <br /> T 510 East Magnolia Street <br /> l— Stockton, CA 95202-1893 <br /> NOTE TO VENDOR: The provisions on the reverse hereof constitute s part of this service order. Submit Invoices In triplicate noting this <br /> S. O. No. and the services provided to the above address. Vendor is to sign Invoice if not on printed bill head. Service Order Number <br /> r <br /> 175-T430169 <br /> Requesor—Office/Program <br /> v S.J. County Public Health Services R. Bippus/Plant Ops <br /> D Environmental Health Division cost Estimate Information <br /> °a P.0. Box 2009 Cost Estimate: <br /> Stockton, Cts 95201 J Total: . 1,530.00 <br /> L <br /> Labor:$ Parte: i <br /> Estimate quoted by (name) Date obtained <br /> Taxpayer No: SIB U ETHU <br /> This service order is your authority to perform the services described below: <br /> 1995 2380 Undeground Tank Permit Fee. Facility ID# 004023. Nine (9) each at <br /> $170.00 per tank.. <br /> Not to exceed: $1,530.00 <br /> PAID BY <br /> CHECK NO-Z <br /> 0--7 <br /> ' cv'.n'Nyr <br /> Authorize '�.. <br /> byd _- <br /> ( eview ng Officer <br /> signature) <br /> FISCAL OFFICE USE ONLY <br /> Estimated Cost =Objecdve <br /> egory (Code and Title) Fiscal Year I hereby certify upon my own personal knowledge that budgeted funds <br /> $ 5d0.00 Fees are available tar the period and purpose of the expenditure stated above. <br /> of Ez nditure item Code AccountingDa <br /> Fund TitlePe Officer D <br /> SF 4558 378. 15 70013 Signature 7 l� <br /> Distribution: This service h s been completed in a manner acceptable to <br /> White Vendor the State and approved for payment. <br /> Yellow DDS Accounting Office <br /> Goldenrod Requestor Authorization/DDSA t. ' <br /> Green Requestor File Copy AMUL Pink Facility File Copy W(Requestor's Signature) 1Dare) <br />