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Advance Description (Work Items and Expenditures) — use an additional page if necessary <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Total Advance to be Paid <br />$ <br />M I N N E S O T A <br />MDH <br />DEPARTMENToFHEALTH <br />Division of Environmental Health <br />Section of Drinking Water Protection <br />P.O. Box 64975 <br />St. Paul, Minnesota 55164 -0975 <br />651/201 -4700 <br />Source Water Protection Plan Implementation Grants <br />Advance Invoice <br />I Grantee Information <br />PWSID: <br />System: <br />Address: <br />Program Contact Person: <br />Phone: <br />Fax: <br />E -mail: <br />I Advance Requested <br />The Grantee certifies this invoice to be true and correct, <br />Authorized Grantee Signature <br />Grant Manager's Signature <br />Date <br />For Minnesota Department of Health Use Only: <br />Date <br />Exhibit B <br />Invoice Field <br />PO: <br />Period of Service: <br />Approved by: <br />Date sent to F.S: <br />