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FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION <br />REQUEST FOR PAYMENT- PART 11 <br />REIMBURSEMENT DETAIL <br />Grantee Name: <br />Payment Request No.: <br />DEP Agreement No.: <br />Vendor Name <br />Invoice Invoice Amount Local Share or Other <br />Invoice Date Funding or Amount Requested Amount (3) Check Number Task/Deliverable <br />Number (1) Number (4) <br />Not Requested (2) <br />Totals: <br />$ <br />DEP Agreement No. NSO45 Exhibit C, Page 5 of 6 <br />