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Check Requisition Form <br /> Form 3500 <br /> Vendor No.: <br /> mADate Needed: 4/26/2023 <br /> IMEWWWROMIRM3 Date on Check: <br /> Total Amount: $6,000.00 <br /> Payable To: Colorado Division of Reclamatin,Mining and Safety RECEIVEn <br /> Attention Peter Hays APR 2 6 2OZ3 <br /> 1001 E.62nd Ave <br /> Dever,Co 80216 DIVISION OF RECLAMATION, <br /> Reference: Violation#MV-2023-004,Permit#2022-006 MINING &SAFETY-MINERAIS <br /> INVOICE# JOB or EQUIPMENT# PHASE CODE ITEM# COST TYPE GIL# AMOUNT <br /> 1 102121 196320-1 1 3 $6,000.00 <br /> Total- $6,000.001 <br /> Requested By: Tyson Geist <br /> Approved By: Tyson Geist <br /> Instructions: Please mail ASAP aabove and proivde receipt of disbursement so I can provide to DMRS <br /> Please make sure this sheet is attached with the check when mailing <br /> SEMA Company Manual <br /> SEMA Construction, Inc. 3500 Check Requisition.docx Forms(10112) <br />