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2003-057
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2003-057
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Last modified
2/2/2017 10:25:13 AM
Creation date
9/30/2015 6:23:10 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Miscellaneous
Approved Date
03/04/2003
Control Number
2003-057
Agenda Item Number
11.H.3
Entity Name
Department of Evironmental Protection
Subject
North County Reverse Osmosis Brine Relocation Project
Archived Roll/Disk#
3160
Supplemental fields
SmeadsoftID
3179
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ATTACHMENT B <br /> Disbursement Request Form <br /> Legislative Projects (Lp) Grants <br /> 1 . Grantee/Recipient Indian River County <br /> 2 Project Number LP0328 Date of Request <br /> 2 Disbursement Request Number Required Match % <br /> 3 . Disbursement Request Number <br /> 4 . Type of Request: Partial ❑ Fina ❑ <br /> 5 . Federal Employer Identification Number <br /> 6 . Mail ❑ EFT ❑ Send Remittance to : <br /> Disbursement Details <br /> (cumulative amounts rounded to the nearest dollar) <br /> 1 . Planning (attach invoices) $ <br /> 2 . Engineering (attach invoices) <br /> 3 . Construction and Demolition (attach pay estimates) <br /> 4. Technical Services during Construction (attach invoices) <br /> 5 . Other (must be specified in agreement) <br /> 6 . Total cumulative to date $ <br /> 7. Disbursements previously requested $( ) <br /> 8 . Amount requested for disbursement $ <br /> (Line 6 minus Line 7) <br /> * * SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: ** <br /> Florida Department of Environmental Protection <br /> Bureau of Water Facilities Funding MS 3505 <br /> 2600 Blair Stone Road <br /> Tallahassee, Florida 32399=2400 <br /> DEP Agreement No . LP###, Attachment B , Page 1 of 3 <br />
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