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Minnesota <br />Department of Health <br />Source Water Protection Plan Implen <br />CI <br />Exhibit A <br />Environmental Health Division <br />Drinking Water Protection Section <br />P.O. BOX 64975 <br />Paul, '0975 <br />vro,, <br />tation Grant Invoice <br />GRANTEE INFORMATION <br />PWSID: <br />System Name: <br />Address: <br />Contact Person Name: <br />Phone: <br />E-mail: <br />Fax <br />INVOICE INFORMATION <br />Is this the final invoice? <br />Yes <br />D No <br />WORK ITEMS AND EXPENDITURE DESCRIPTION — use an additional page if necessary <br />5 <br />s <br />$ <br />Total Expenditures $ <br />Net Invoice Amount to be Paid <br />DISCLAIMER AND SIGNATURE 1 declare that no part of this claim has been previously billed to mou, and that the Total Expenditures reflect cnly <br />charge related to the source irrater protection project. also declare that the data on this document Is correct and all transactions that support this claim were <br />made in accordance with all applicable Federal and State statutes and regulations. <br />Authorized Grantee Signature Date <br />FOR MINNESOTA DEPARTMENT OF HEALTH USE ONLY <br />Grant Manager Signature Date <br />PO: <br />Period of Service: <br />Approved by: <br />Date sent to F.S: <br />