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<br />DRAFT ONL Y - NOT FOR PA YMENT <br />--- (5/9/2007 - 5/16/2007) <br />Emergency Equipment - Use Invoice Invoice#:AssignedWhenOriginalisPrinled <br />This invoice has not received a final audit and is subject to change prior to payment Official #: 01 Page 1 of 1 <br /> <br />I. :ON,:r~ACT?!&\~nd address) 2. INCIDENT OR PROJECT NAME <br /> _.Llt l_- HAM LAKE MN-SUF-070072 <br /> FIRE DEPARTMENT <br /> 1710 COUNTY HWY 10 - 3. AGREEMENT NUMBER (From OF-294\ <br /> SPRING LAKE PARK MN 55432 000000004 <br /> 4. EFFECTIVE DATES OF AGREiMENT <br /> b.TINIEIN: 41-6038888 a. Begmmng: b. Ending: <br /> 5/8/2007 12131/2007 <br />5. EQUIPMENT (List make, model, serial no" elc.) ENGINE, TYPE 6 6. POINT OF HIRE (Location when hired) <br /> Unique 10: 2004 FORD F350 250 GAL ELK RIVER <br /> Make: 250 GAL TYPE 6 ENG 7. DATE OF HIRE 8. TIME OF HIRE <br /> Model: 05/912007 0000 <br />9. ADMINISTRATIVE OFFICE FOR PAYMENT 10. THE WORK RATE IS BASED ON ALL OPERATING <br /> . SUPPUES BEING FURNISHED BY <br /> MINNESOTA DEPT. OF NATURAL RES IiZI CONTRACTOR(wel) -1'1 GOVERNMENT(d~\ <br /> 402 SE 11TH ST I I. OPERATOR FURNISHED BY <br /> IiZI CONTRACTOR 0 GOVERNMENT <br /> GRAND RAPIDS MN 55420 12. RESOURCE ORDER NUMBER E-128 <br />13. YEAR 14. WORK OR DAILY RATE 15. SPECIAL RATE 16.TOTAL AMOUNT 17. GUARANTEE 18. AMOUNT <br />2007 B. UNITS b. RATE c. AMOUNT a. UNITS b. RATE c. AMOUNT EARNED <br />MO WORKED WORKED (14c+15c) <br />DA (Ml'HMlA) (MIlHRJDA) <br />5 9 101lIl $150.00 $1,500.00 See Nexl Line See Nexl Line See Next Line <br />5 9 61lR $150.00 $900.00 $2,400.00 $2,400.00 <br />5 10 15iiR $150.00 $2,325.00 $2,325.00 $2,325.00 <br />5 11 131lR $150.00 $1,950.00 $1,950.00 $1,950.00 <br />5 12 151lR $150.00 $2,250.00 $2,250.00 $2,250.00 <br />5 13 141lR $150.00 $2,1 00.00 $2,100.00 $2,100.00 <br />5 14 131lR $150.00 $1,950.00 $1,950.00 $1,950.00 <br />5 15 13iiR $150.00 $2,025.00 $2,025.00 $2,025.00 <br />5 16 lliiR $150.00 $1,725.00 $1,725.00 $1,725.00 <br />19. CHARGE CODE 120 OBJECT CODE 23. GROSS AMOUNT DUE $16,725.00 <br /> P9DER5 <br />21. EQUIPMENT WAS Ii'! RELEASED o WITHDRAWN 24. ITEM 23 FROM PREVIOUS PAGE <br /> Dale: 5/16/2007 Time: 18:00 25. TOTAL AMOUNT DUE $16,725.00 <br />22. REMARKS Prior Partial Payments 26. DEDUCTIONS (attach statement) $220.10 <br /> None <br /> 27. ADDITIONS (attach statement) $0.00 <br /> 28. NET AMOUNT DUE $16,504.90 <br />29. NOTE: CONTRACT RELEASE FOR AND IN CONSIDERATION OF RECEIPT OF PAYMENT IN TIlE AMOUNT SHOWN ON "NET AMOUNT DUE" LINE 28. <br />CONTRCTOR HEREBY RELEASES THE GOVERNMENT FROM ANY AND ALL CLAIMS ARJSING UNDER THIS AGREEMENT EXCEPT AS RESERVED IN <br />"REMARKS" BLOCK 22. <br />30. CONTRACTORS SIGNATURE I 3 t. DATE 32. RECEIVING OFFICER'S SIGNATURE .133. DATE <br /> DRAFTONLY-NOTFORPAYMENT Slit },,7 DRAFT ONL Y - NOT FOR PA YMENT <br />34. PRINT NAME AND TITLE 35. PRINT NAME AND TITLE <br /> r;A~L1 p, t. 0 (I: f' L-d_ <br />Printed: 05/1.6/2007 09,31 / Date Form Modifled:513/02 OPTIONAL FORM 286 <br />