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Certification of Missing Receipt <br /> (may also be used for Illegible or damaged receipts) <br /> Date of Purchase: September 3,2015 <br /> Vendor Information: <br /> Name: Bolinger&Queen <br /> Address: 32874 J Road Hotchkiss,Co 81419 <br /> Phone: 970-872-3371 <br /> Description of item Quantity Unit Price Extended Price <br /> 15-in diameter HDPE Culvert 100 feet 12.34/LF 1,234.00 <br /> Purchase Total 1,234.00 <br /> Original receipt/invoice is: OXXMIssinglLost ❑Illegible ❑Damaged <br /> a"If recetptllnvotce Is Illegible or damaged,It must accompany this form•" <br /> CARDHOLDER NAME: Camille Price <br /> SIGNATURE: erruk, 6221,ei . DATE: _September 9,2015__ <br /> APPROVING OFFICIAL NAME: 46z / S r�— <br /> SIGNATURk4 ",.. DATE: / , � `S— <br />