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STATE OF CALIFORNIA AGENCY BILLING I CONTRACT/DELEC""TON NO. PAGE OF PAGE <br /> CON.7RAC:DELEGATION PURCHASE IER CODE <br /> STD.65(REV.4-92) 1 7 2 0 0 y-ad-1720 01 of 01 <br /> S B DATE(MONTH,DAY,YEAR) <br /> H NORTHERN CALIFORNIA,WOMEN'S FACILITY I Central Valley Regional Accounting Office June 20,2000 <br /> I 4790 Frontier Way#5 L NCWF <br /> P Stockton,CA 95205 L P.O.BOX 4147 AGENCY ORDER NUMBER <br /> Stockton,CA 95204-0147 19-2-9-1641 <br /> T Attn: T VENDOR: THIS NUMBER MUST BE <br /> O O SHOWN ON INVOICE. <br /> TO S J COUNTY PUBLIC HEALTH SERVICES COMPLETE ONLY <br /> FIRM ENVIRONMENTAL HEALTH DIVISION WHEN TO BE USED AS VENDOR'S INVOICE <br /> ADDRESS <br /> 304 E.WEBER,31D FLOOR I hereby certify that this is a VENDOR'S INVOICE <br /> (Type or STOCKTON CA 95202 true and just bill and payment NUMBER <br /> Print has not been received <br /> .Legibly) VENDOR'S SIGNATURE <br /> Attn: <br /> TITLE(OWNER,MGR.,CLERK,ETC.) <br /> PHONE NUMBER <br /> NOTICE 1.Show the Agency order number and Contract/ 4.Vendor's Federal Employer Identification Number VENDOR'S TAXPAYER I.D.NUMBER(FEIN) <br /> TO Delegation number on your invoice. is required. <br /> MERCHANT 2.Show cash discounts offered on your invoice. 5.Submit original receipted expense bill if your invoice <br /> 3.Submit invoice in triplicate. If not on printed bill includes prepaid transportation charges. <br /> head,vendor please sign invoice. 6. All shipments shall be F.O.B.destination unless <br /> otherwise stated on this order. <br /> DATE WANTED SHIP VIA TERMS <br /> NET 30 <br /> ITEM NO. QUANTITY UNIT COMMODITY CODE DESCRIPTION UNIT PRICE EXTENSION <br /> SM HW GEN.<5 TONS/YR <br /> 1. 1 EA #IN0070529—ARCH ROAD 110.00 110.00 <br /> SM HW GEN<5 TONS/YR <br /> 2. 1 EA #IN0070653—FRONTIER WAY 110.00 110.00 <br /> C'7 <br /> 3. rD <br /> 4. REVOLVING FUND CHECK REQUESTED <br /> 5. <br /> 6. <br /> i <br /> 7. <br /> 8. <br /> 9. � <br /> 10. <br /> FORCED,CONVICT AND INDENTURED LABOR LANGUAGE <br /> "No foreign made equipment,materials,or supplies furnished to the state pursuant to this contract may be produced in whole or in part by forced labor,convict labor,or <br /> indentured labor. By submitting a bid to the state or accepting a purchase order,the contractor agrees to comply with this provision of the contract." <br /> FOB SALESTAX <br /> DESTINATION N/A <br /> C A PROGRAM CATEGORY(CODE AND TITLE) FUND TITLE (OPTIONAL USE) TOTAL <br /> A A 99 Clearing Acct. GENERAL 1900 2Za� $220.00 <br /> R I ITEM CHAPTER STATUTE FISCAL YEA OBJECT OF EXPENDITURE(CODE AND TITLE) <br /> G S <br /> E S 5240-001-0001(5288) 50 1999 99/00 346 <br /> T <br /> CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER UNENCUMBERED REMAINDER AFTER <br /> HEREBY CERTIFY,On my own personal knowledge that this order for the purchase of the POSTING TIES ORDER TO ALLOTMENT <br /> items specified above is issued in accordance with the procedure prescribed by law governing the EXPENDITURE LEDGER <br /> purchase of such items for the State of California;that all such legal requirements have been fully ADJUSTMENT <br /> complied with. INCREASING ENCUMBRANCES <br /> TITLE <br /> KENNETH M.RITZMAN,PROCUREMENT OFFICER ADJUSTMENT <br /> (20 943- 00 EXT.5087 DECREASING ENCUMBRANCES <br /> SIG TI I CERTIFI D CO CT(SIGNATURE) <br /> DISTRIBUTION: Copy 1 -Vendor;Copy 2-Procurement;Copy 3 -Packing Slip;Copies 4-7-Miscellaneous(Agency) <br />