ENVH REFUNDCOUNTY OF HARNETT
CHECK REQUEST FORM
NORTH CAROLINA
Account Number: 110-0000-345.18-00 Fx]Mail to payee
Project Number: ❑ Check to be picked up by:
Vendor Name: John A. & Debra J. Sylvestri
Vendor Number: (Requires approval of Finance Officer)
Remittance Address: 120 First Calvary Road Approved: Disapproved:
Date 11a3`lol- Fort Leavenworth, KS 66027
Description
Amount
Environmental Health Soil Evaluation Fee
$ 750.00
HTE# 12-5-28204
Location: McLean Chapel Church Rd-Lot 13
Total Amount Due
$ 750.00
Reason for check request: Above listed applicants decided they did not want to proceed at this time, and requeste(
a refund. No site visit had been made by Environmental Health.
This check request has been examined by me and is hereby approved for payment.
Department Head or Authorized D signee 7 Date
Graham H. Byrd, R.E.H.S.
X~4,
A T ' in 4 ument has been
preaudited in the manner required
by the Local Government Budget
and Fiscal Control Act
Harnett County Finance Director