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' f I 9 <br /> ..Yr +i-¢ 35,1 +F.z.Z.'i i-"�ji.C'3t,+?:w x F _ .` <br /> State of Washington n 1` 1' "''"se^` <br /> Form rFsi rf, � •� >Fw r5 � }ii� ' <br /> A-19 lA 4= A-,A6e CY NQ a.4t.-49 ltigiN '' — . - '�� �14, <br /> ' ' '`. r 46� r a� F �1�7 y� �� <br /> et <br /> (Rev. 'kt iv^:„Y INVOICE VOUCHER ,+ • 7$ y �� 'l tii3s � rp f- ru` ` t 1 <br /> '' <br /> 10/00) i f 1 ;LT :,(4 � kw$ > s . <br /> , t 1' C �0r r <br /> ECY 060 . �" L ! � ' 4 � <br /> , i ,.„.-.,..:,:.,,..„1",; 9a1x*,, a- s- 1 <br /> 02 i ; 1 �i.i. _ •, i .}.r �st�!, <br /> Agency Name 3. Payment Request No. I. <br /> 1. Proj.Off. Lydia Lindwall • 4. Agreement No. G1000088 <br /> Program : SWFAP <br /> Washington Dept of Ecology Vendor's Certificate. l hereby certify under penalty of perjury that the items and <br /> PO Box 47600 totals listed herein are proper charges for materials,merchandise or services <br /> Olympia,WA 98504-7600 furnished to the State of Washington,and that all goods furnished <br /> 2. Grant/Loan/Recipient and/or services rendered have been provided without discrimination <br /> (Warrant is to be payable to:) because of age,sex,marital status,race,creed,color,national origin, <br /> handicap,religion,or Vietnam era or disabled veterans status. <br /> CttyofEverrttt..n-.:,.'N-4r. <br /> r .' s �, ti �. S. By: <br /> 3200'C� t ata€. y ,, (x) <br /> -1` ':.. { a s #;.r �"t'' R' (sign in blue ink) <br /> E�eta d kms+;: . u * <br /> „, ,, "�g.4a, �:,' .a r j 'Title: Date: <br /> L1ap� t i <br /> . y , Iii Contact Person Telephone Number <br /> Received By Date Received <br /> 7. Effective Date: 7/1/2007 <br /> Expiration Date: 11/30/2009 Project Officer Approval for Payment/Performance Certification <br /> 8.Billing Period from: 7/1/2007 <br /> to: 10/31/2008 Signature: Date: <br /> 9.Fund Source Name: SBCA <br /> 10. Amount of Grant/Loan from.Fund: $200,000.00 <br /> 11.Cumulative Amount Requested: $200,000.00 <br /> 12.Previous Cumulative Amount Requested $0.00 <br /> 13.Current Request/Payment Due $200,000.00 <br /> 114.Grant/Loan Remaining in the Fund $0.00 <br /> All payments are made subject to federal and/or state audit <br /> VENDOR MESSAGE USE 0811,10.DOC DATE PMT DUE DATE CURRENT DOC NO, REF.DOC NO. VENDOR NO. TAX <br /> J <br /> MASTER MEC wORRCLASf COUNTY CITY/TOWN <br /> SUB SUB PROI AMOUNT INVOICE NUMBER <br /> REF TRANS 0 FUND SUB SUB ORG PROJECT PRO! PIAS <br /> DOC CODE OBI INDEX BUDGET <br /> SUF D APPN PROGRAM OBJECT ALLOC UNIT MOS <br /> INDEX INDEX <br /> PARRINT TOTAL WARRANT NUMBER <br /> ACCOUNTING APPROVAL FOR PAYMENT DATE <br /> Ecology is an Equal Opportunity Employer. <br /> 41 <br />