Standardized_Invoice-APCD-Custom-Invoice-for-Locals.xlsx

	A	C	D	E	F
1	INVOICE NUMBER: (maximum 12 characters)
2
3	To: Colorado Dept. of Public Health & Environment		From:
4	Attn: APCD Fiscal Officer
5	Air Pollution Control, B1-ADM
6	4300 Cherry Creek Drive South
7	Denver, CO 80246
8	Email: CDPHE_APCD_Fiscal@state.co.us
9
10	FEIN#:	Dates:	From:	To:	Final Bill:
11	Contract/PO #
12
13	Activity/Task	Hourly/Task Rate	Enter No. of Tasks/Samples Completed	Hours Paid Per Task	Reimbursement Requested
14	Title V Source Inspections	$0.00		0.00	$0.00
15	Syn Minor Source Inspections	$0.00		0.00	$0.00
16	Minor Source Inspections	$0.00		0.00	$0.00
17	Complaint Investigation	$0.00		0.00	$0.00
18	Open Burning Permits	$0.00		0.00	$0.00
19	Professional Training Activities	$0.00		0.00	$0.00
20	Other:	$0.00		0.00	$0.00
21	Gaseous Site:	$0.00		0.00	$0.00
22	Gaseous site:	$0.00		0.00	$0.00
23	Gaseous site:	$0.00		0.00	$0.00
24	Gaseous Training	$0.00		0.00	$0.00
25	Air Toxics	$0.00		0.00	$0.00
26	Operation & Maintenance of PM10 Monitors	$0.00		0.00	$0.00
27				Enter Number of Actual Hours
28	Operation & Maintenance of PM10 Low Vol Monitors	$0.00		0.00	$0.00
29	Operation & Maintenance of PM2.5 TEOM Monitors	$0.00		0.00	$0.00
30	Operation & Maintenance of PM2.5 FRM Monitors	$0.00		0.00	$0.00
31	Operation & Maintenance of PM2.5 Speciation Monitors	$0.00		0.00	$0.00
32	Asbestos	$0.00		0.00	$0.00
33	CFC Activities	$0.00		0.00	$0.00
34	TOTAL				$0.00
35
36	To be Signed by Contractor/Vendor
37	I/We affirm the claimed expenses comply with the budget provisions of the contract and are reasonable and necessary, that all relevant progress or other reports have been timely filed, and all contract milestones and/or tasks related to the billing period have been achieved.
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39	Signature & Title			Date
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41	To be Signed by CDPHE Program Director or Delegate
42	I affirm that I or my staff have reviewed the contractor's invoice and supporting documentation (as required), progress reports and other communications with the contractor, and believe to the best of my knowledge, that the contractor is in compliance with all contract provisions.
43
44	Signature & Title			Date
45
46	To be Signed by CDPHE Fiscal Officer or Delegate
47	I certify that the claimed expenses have been reviewed by me for compliance with the requirements of the funding source and the State of Colorado Fiscal Rules, and are charged to the appropriate funding source.
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49	Signature & Title			Date
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