Laserfiche WebLink
Gran Agreement Number <br /> Between the Minnesota Department of Health and City of Centerville <br /> CHID Division of Environmental Health Exhibit A <br /> M I) H Section of Drinking Water Protection <br /> P.O. Box 64975 <br /> St. Paul, Minnesota 55164-0975 <br /> 17171 i11i'irT1:If1iiJ <br /> 651/201-4700 <br /> Source Water Protection Plan Implementation Grants <br /> Invoice <br /> Grantee Information PWSID: <br /> System Name: <br /> Address: <br /> Contact Person Name: <br /> Phone: Fax: <br /> E -mail: <br /> Invoice Information <br /> Is this the final invoice? ❑ Yes ❑ No <br /> Work Items and Expenditure Description — use an additional page if necessary <br /> Total Expenditures $ <br /> Deduct amount of advance received $ <br /> Net Invoice Amount to be Paid $ <br /> The Grantee certifies this invoice to be true and correct. <br /> Authorized Grantee Signature Date <br /> For Minnesota Department of Health Use Only: <br /> Grant Manager's Signature Date <br /> Invoice Field <br /> PO: Approved by: <br /> Period of Service: Date sent to F.S: <br /> 7 <br /> 68 <br />