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1 a�i, i vi i <br /> Receipt <br /> Washington State Department of Labor and Industries <br /> Customer: STEPAN SAVCHIK <br /> Address: 10115 23RD AVE W <br /> City: SNOHOMISH State: WA Zip: 98204 <br /> -- Fiscal Transaction Receipt -- <br /> Fiscal Transaction: 104925998 <br /> Created: 9/14/2015 <br /> Payments: $90.30 <br /> -- Payments -- <br /> Type Amount Payer Reference <br /> Credit Card $90.30 STEPAN SAVCHIK 1160521894 <br /> -- Services -- <br /> EP2573777 <br /> Description Reference Quantity Price <br /> -Single or Multifamily Resid EP2573777 670 $90.30 <br /> NUT�:All refund�equests must be mac�e in writing. Refund.s may�equire p��ocessing through <br /> ce�tYal office and we cannotguarczntee imrnediate refunding ofservices. <br /> http://field-services.apps-inside.lni.wa.gov/TrontCounter/FCRevRecWeb/ReceiptPrint.asp... 9/14/2015 <br />