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