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~ '~ <br />PURCHASE REQUId~TI(~N .III IIIII~~IIIIII III <br />SUGGESTED VENDOR AND ADDRESS PURCHASE ' GGE• ED VENDOR AND ADDRESS ORDER NUMBER <br />AZCO Construction ~ <br />2055 H 50 VENDOR NUMBER VENDOR NUMBER <br />Penrose CO ZIP 81240 Z'P <br />TERMS Tax ID 1184-1023014 Foe TERMS Fob <br />DOC ID CODE NO. <br />Yr <br />~ ~?. - <br />~ / <br />J <br />A E '~ ~ T <br />4UD F4 A T PV~TYPE . <br />/r <br />UNO AGENCY <br />2 7 0 P K A ORG SUB~ORG APPR CODE BS ACOT OBJECT <br />C C C 8 m 1 2 2 ~ 2 3 1 SUB~OBJ REV SRC <br />m <br />SUB.REV PROGRAM <br />m M N R C GBL FUNCTION REPORTING CAT peOJIJOB NO <br />~ ~ ~i~ OFF REC ACCT <br /> L~ <br />BILL TO -Name artl Address SHIP TO ~ Name and Atltlress <br />Division of Minera ls and Geology Desingated Job Site <br />1313 Sherman St., Rm. 215 <br />Denver, CO 80203 <br />REQUESTING AGENCY ~ Name and Atltlress TELEPHONE PERSON(S) TO CONTACT <br /> (303) <br />Same as bill to 866-3567 Maggie Van Cleef <br /> ax <br />(303) <br /> C 832-8106 <br />I heresy cenily Ihal Ins sYpPllas or selVices d ar ¢Ca55drY ler Iha SUCCe551 oiler Ibn I t apen and me <br />quanl~ly requested is the miNmum amoun n tlc al s na to wv sam . <br /> <br /> `. AUTHORIZED SIGNATURE <br />ITEM I QUANTITY <br />NO UNIT GOMMUD NUMBER AND I <br />COMPLETE DESCRIPTION OF ITEM OR SERVICE UNIT j AMOUNT <br />COST <br /> REFERENCE PRICE AGREEMENT A_ jl j <br /> 'Trinidad Basin Mining Company <br />~ '. 'Permit 11C-81-048 <br />I ;Emergency Sediment Pond Repair <br />I <br />1 ~ 1 Job Excavate embankment failure, install CSP N/A $4,385.00 <br /> ;and anti-seep ring. <br />2 i 80 Ln. Ft; 12-inch diameter, 16 gauge CSP .. $12.00 460.00 <br />1 <br />3 ~ 1 <br />Each Larger anti-seep ring, if required <br />N/A 50.00 <br />i TOTAL S`J395.00 <br />I <br />REOUE STED DELIVERY DATE <br />]95-5]-05-]tal - - - --- <br />WHITE ~ Pvrchavig Copy YELLOW ~ Accounts 8 Gomrol Copy PINK ~ Agency GopY GOLDENROD ~ Depanmem Gopy <br />