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Okaloosa County BOCC — August 6, 2013 — Harcros Contract Payment Approval Form and Invoice — 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# | peparrMENT# | ACCOUNT # AMOUNT
(f Applicable) (Uf Applicable) 59 A, G f A,
340075057 4101 $52602 1,456.00
WATER
TOTAL | $ 1,456.00
APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date)
CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: ofey DATE:
€
COUNTY SUPERVISOR/PROJECT MANAGER: Jug Ren £Ufa9eP> / Le vA Za ( DATE: p2o- 7-/3
DEPARTMENT DIRECTOR: . \,, It tke alh DATE: [0/ Z/ 2013
= Y ot 7 /
CONTRACTS & GRANT MANAGER: DATE:
COUNTY ADMINISTRATOR: DATE:
(Payments>$25,000.)
— =
y FINAL PAYMENT
NO__ (ff "Yes", forward to Purchasing Services Coordinator for Close-Out)
DATE: PURCHASING DIRECTOR:
(Per Initial Agreement)
DATE: CONTRACTS & GRANTS MANAGER:
(All Contracts)
DATE: COUNTY ADMINISTRATOR APPROVAL:
(Per Initial Agreement)
DATE: BOARD APPROVAL:
(Per Initial Agreement)
I —}
COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY
FISCAL YEAR:
DATE RECEIVED:
REVIEWED BY
347932700
af
HARCROS
05991960
OKALOOSA COUNTY
302 N WILSON STREET
SUITE 203
CRESTVIEW, FL 32536
SOLD TO
Harcros Chemicals Inc
FEDERAL |.D. NO. 43-1935062
Phone: 251 457 5316
1480 TELEGRAPH RD.
MOBILE, AL 36610
SHIP TO
INVOICE NUMBER
340075057
INVOICE DATE
03-OCT-2013
09083822
OKALOOSA COUNTY
RUSSELL STEVENSON PLANT
3182 HWY. 98 WEST
MARY ESTHER, FL 32569
( SAME UNLESS )
SHOWN
SHIPPING DATE SHIPPED VIA SHIPPING POINT FREIGHT/FOB
03-OCT-2013 HARCROS TRUCK MOBILE Dest/Freight Prepaid
SALESPERSON NO. CUSTOMER ORDER NUMBER TERMS OF SALE TAX STATUS
T - TAXABLE
021 AMA c091764ws#259 NET 30 2. EREMPT
QUANTITY DELIVERED |TY.PKG. DESCRIPTION UNITS DELIVERED] TYPE UNIT | TAX |PRICE PER UNIT| AMOUNT
2 |CY Chlorine 4000 |LB E 0.364007 1456.00]
2000# Cylinder-Harcros
05847
2 |EA Deposit - 2000# Chlorine Cyl 2 |EA E 0.00000
DOO71
Total Tax: 0.00
Your account is subject to a FINANCE CHARGE, at a PERIODIC RATE OF 1. 5% per ‘month = | TOTAL
(ANNUAL PERCENTAGE OF 18%) applied to all unpaid account balances, not paid within the ferme” -| AMOUNT 1,456.00/
of sale. This rate will be uniform in all states, except in ‘those states where interest collected gay be DUE
more or less depending entirely on the state’s statues. a aS =
O All G | N A L N V O I C E PLEASE REMIT PAYMENT TO: —
PLEASE RETURN A COPY OF THIS INVOICE WITH = GS 3 se
PAYMENT OR REFERENCE INVOICE NUMBERS ON HARCROS CHEMICALS INC
YOUR CHECK P.O. Box 74583
Chicago, IL 60696
For Terms and Conditions of Sale, please visit: http://www.harcros.com/invoiceterms.asp
or See your BOL
Your Business 7s Abprectated