HomeMy WebLinkAboutGB000112 - REQUEST FOR CHECK CLAIM OF
NAME - PLEASE PRINT OR TYPE
REQUEST FOR CHECK OMID RESIDENCE TRUST
STREET ADDRESS
To: COUNTY OF ORANGE 16 CHANNEL VISTA
AUDITOR-CONTROLLER CITY AND ZIP CODE
P.O. BOX 567 NEWPORT COAST, CA 92657
SANTA ANA, CA 92702 SOCIAL SECURITY NUMBER TAXPAYER IDENT. NUMBER
DATE DESCRIPTION AMOUNT
12/30/03 Project: GB000112
Job Location: 16 CHANNEL VISTA NEWPORT COAST
Parcel No: 152067
Receipt: 022025 Dated 09/21/00
Deposit Order : 22129 Dated 09/22/00
$ 5,800.00 Deposit Amount
$ 4,932.46 Less Costs
$ 133.60 Less Plan Check Refund $ 733.94
$ 733.94 Refund Amount
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Prepared by PDSD Accounting, Norbert Ponce(714)796-0302 TOTAL $ 733.94
AUTHORIZATION
Minute Order Date County Ordinance No. Vendor No.
Board Resolution No. P.O. / Encumbrance No. Other
A=
DEPARTMENT'S USE COMPLETE IN DETAIL U '
SUB` . SUB KEPT B S <. F
WND .AGCY. QRG tCl V Q8 Qi3 ..R F2EV Jt3B NVMOER °CAT(S ACCT' AMt UNT CST.
113 113 0018 9120 $ 733.94
TOTAL PAYMENT $ 733.94
I HEREBY CERTIFY THAT THIS CLAIM A EXPENDITURES AUTHORIZED AND APPROVED DAVID E. SUNDSTROM,Auditor-Controller
IS TRUE AND CORRECT AND THAT f y APPROVED BY
PAYMENT HAS NOT BEEN RECEIVED BY 7,
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X w � V-L'ISIIo3
CLAIMANT DEPT. HEAD OR AUTHORIZED SIGNATURE DEPUTY
003 F8500-6(8/93)
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