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Okaloosa County BOCC — August 6, 2013 — Executed Payment Approval form — reading text
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CONTRACT/LEASE
PAYMENT APPROVAL FORM
COMPLETE AND FORWARD TO THE NEXT DEPARTMENT
COMPLETED BY DEPARTMENT
DATE: 10/5/2013
VENDOR NAME: HARCROS CHEMICALS INC VENDOR #: 002570
CONTRACT/LEASE#: C09-1764-WS
TASK COUNTY/FEMA
VENDOR BUDGET
INVOICE # ORDER # PROJECT # DEPARTMENT ¢ | ACCOUNT # AMOUNTS
Of Applicable) (f Applicable) SSA GIA | J
340075057 4101 552602 Ie 1,456.00
—WAPER— _|p/
SEWER N™
TOTAL | $ 1,456.00 1 (
APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date)
CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: DATE:
COUNTY SUPERVISOR/PROJECT MANAGER: al befoay> L Len “ Za { DATE: pw- 7-/3
DEPARTMENT DIRECTOR: . \_, th DATE:_{0/ Z/ 2013
\
(i CONTRACTS & GRANT MANAGER: DATE:
COUNTY ADMINISTRATOR: DATE:
(Paymenis>§25,000.)
FINAL PAYMENT
FINAL PAYMENT YES Ko _ Of "Yes", forward to Purchasing Services Coordinator for Close-Out)
DATE: PURCHASING DIRECTOR: 7 ey
(Per Initial Agreement)
DATE: |QO-f-13 CONTRACTS & GRANTS MANAGER: Corral) aS oun
(All Contracts)
DATE: |6 -% -(> COUNTY ADMINISTRATOR APPROVAL: \_4S
(Per Initial Agreement) VA Vi
DATE: BOARD APPROVAL:
(Per Initial Agreement)
COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY
FISCAL YEAR:
DATE RECEIVED:
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