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1995, 11-05 Permit 95007500 RefundPv# Dept VENDOR Y HEATX. 13821 S. MURPHY ROA:. r7HF*J Y4 WA 990Ci:c Vendor Contact/Tel LGFS PAYMENT DOCUMENT SPOKANE COUNTY AUDITOR SHIP TO: Confirming Order BILL TO: Charve Order # Bid ID Blanket# RC# VI# FOB: ACCTG. PERIOD: COMMENTS: COMM LN# DESCRIPTION COMMODITY NO PO DATE: BLDG; ROOM: DELIVERY DATE: WAREHOUSE: F.NTFRFID BY - REF ACCT LINE QUANTITY UNIT BUYER PURCHASING TZIRFCTOR' UNIT PRICE c35C075Gu-18301 E. INDIANA =- PROJECT CANCELED — 80% RF''!" $49.00 X 80% = $39.2u PAGE TOTAL: DISCOUNT TOTAL: FREIGHT TOTAL: SALES TAX TOTAL: PURCHASE ORDER VALUE: USE TAX TOTAL: TOTAL PRICE 3.9.20 0.00 0.00 0.00 39.20 C.00 LINE NO. FUND I AGCY ORO I SB ORO I ACT OB] SE OBI REV SRC SB REV RPT CAT BS ACCT TOB NO. I PAY THIS AMOUNT I P/F RECEIVING CERTIFICATION Materials noted in quantity J have been received in good condition or contracted for. SIGNED TITLE DATE 5' 11, AC 1/5 95 PAYMENT CERTIFICATION I, the undersigned do hereby certify under penalty of perjury that sufficient funds have been budgeted for this claim, the materials have been furnished, services rendered or labor performed as described herein or contracted for, that the claim is a just, due and unpaid obligation against Spokane County or fund agency indicated above, that I am authorized to authenticate and certify to said claim. SIGNED TITLE DATE .]MINISTRATOR TRAVEL CERTIFICATION I hereby certify under penalty of perjury that this is a true and correct claim for necessary expenses incurred by me and that no payment has been received by me on account thereof. SIGNED TITLE DATE PAGE DEPARTMENT 2