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i <br /> At I N N E S 0 T A Dhdsion of Environmental Health Exhibit B <br /> ' Section of Drinking Water Protection <br /> P.O.Box 64975 <br /> St.Paul,Minnesota 55164-0975 <br /> DFPARTMFNT6�NEAlTH 651/201-4700 <br /> Source Water Protection Plan Implementation Grant Invoice <br /> GRANTEE INFORMATION PWSID: <br /> System Name: <br /> Address: <br /> Contact Person Name: <br /> Phone: Fax: I <br /> E-mail: <br /> i <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 /> Net Invoice Amount to be Paid <br /> DISCLAIMER AND SIGNATURE I declare that no part of this claim has been previously billed to MDH,and that the Total Expenditures reflect only <br /> charges related to the source water protection project.I also declare that the data on this document Is correct and all transactions that support this claim were <br /> made in accordance with all applicable Federal and State statutes and regulations. <br /> I <br /> Authorized Grantee Signature Date <br /> I <br /> FOR MINNESOTA DEPARTMENT OF HEALTH USE ONLY <br /> I <br /> Grant Manager Signature Date <br /> PO: Approved by: <br /> Period of Service: Date sent to F.S: <br /> i <br /> I <br /> I <br /> i <br /> 44 <br />