1995, 10-05Permit: 9501333 RefundIV#
Dept
VENDOR
216 So L^N—Q R -AD
Vendor Cor"Ct/Tel
LGFS PAMENT DOCUMENT
SPOKANE COUNTY AUDITOR
Confammq Order
Change Order #_
Bid ID
Blanket#
RC#
VI#.
FOB: PO DATE: BLDG/ROOM: BUYER
ACCTG. PERIOD: DELIVERY DATE: WAREHOUSE:
COMMENTS- FNTFRET) BY- PURCHASINC DIRECTOR
COMM LN# I DESCRIPTION
COMMODITY NO REF ACCT LINE QUANTITY UNIT UNIT PRICE TOTAL PRICE
MT 'PPi M PTP, - 100% RE9M
PAGE TOTAL: 457.00
DISCOUNT TOTAL: IV, 00
ERFIGHT TOTAL: 0000
SALES TAX TOTAL: OevO
PURCHASE ORDER VALUE:45.011
U:SEE TAX TrTAL' 0000.
LINE N�FUNQ G SB OR
AGCY 1 ORG ACT OBI SB OBI REV SRC SB REV I RPT CAT BS ACCT OB NO. PAY THIS AMOUNT PIF
RECEIVING CERTIFICATION PAYMENT CERTIFICATION TRAVEL CERTIFICATION
Materials noted in quantity J have been 1, the undersigned do hereby certify under penalty of perjury that sufficient funds have been budgeted for this claim, the 1 hereby certify under penalty of perjury that this
received in good condition or contracted for. materials have been furnished, services rendered or labor performed as described herein or contracted for, that the claim is is a true and correct claim for necessary expenses
a just, due and unpaid obligation against Spokane County or fund agency indicated above, that I am authorized to authenticate incurred by me and that no payment has been received
SIGNED and certify to said claim. by me on account thereof.
ik:i T T ELfi :> %ICt E II.VISTRATG
TITLE SIGNED TITLE SIGNED TITLE
10/5/95 10/ /95
DATE DATE DATE PAGE
DEPARTMENT2
TRANSACTION NUMBER: T9501333 DATE: 10/04/95
APPLICANT: WILLMAR FISCHER PHONE=
ADDRESS: 210 S LONG RD
GREENACRES WA 99016
CONTACT NAME: WILLMAR FISCHER PHONE=
TRANSACTION: ON SITE SEPTIC REVIEW FORM AND CERTIFICATE OF EXEMPTION
DOCUMENT ID: 1) CE -663-95 2) 3)
4) 5) 6)
FEE & PAYMENT SUMMARY
ITEM DESCRIPTION QUANTITY
------------------------- --------
CERT EXEMPT: PRE178; 028 1
SEPTIC REVIEW FORM 1
TOTAL DUE _
TOTAL PAID=
BALANCE OWING=
FEE AMOUNT
QR
m.00
99.00
99.00
------------
.00
PAYMENT DATE RECEIPT# CHECK,¢` PAYMENT AMOUNT
10/03/95 00009414 2004 99.00
PROCESSED BY: KATHY CUMMINGS
PRINTED BY: KATHY CUMMINGS
THANK YOU
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