Agenda - Public Works Committee - 01/18/2011

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Work Items and Expenditure Description — use an additional page if necessary $ $ $ $ $ $ Total Expenditures Deduct amount of advance received Net Invoice Amount to be Paid $ $ $ M I N N E S Q T A MDH DEPARTMENT o HEALTH Division of Environmental Health Section of Drinking Water Protection P.O. Box 64975 St. Paul, Minnesota 55164 -0975 651/201 -4700 Source Water Protection Plan Implementation Grants Invoice Exhibit A Grantee Information PWSID: System: Address: Program Contact Person: Phone: Fax: E -mail: Invoice Information Is this the final invoice? Yes ❑ No The Grantee certifies this invoice to be true and correct, Authorized Grantee Signature Grant Manager's Signature Date For Minnesota Department of Health Use Only: Date Invoice Field PO: Period of Service: Approved by: Date sent to F.S: