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STATE OF CALORADO <br />PURCHASE REQUISITION <br /> PuPGNASE <br />ORDER NUYBER AGENCY NAME PR NUMBER <br />SUGGESTED VENDOR AHD ADORE55 E <br /> F/Y DATE FUND ACT CD AGENCY NUMBER <br /> VENDOR NUYBER t ~~ <br /> <br /> ZIP COMMODITY CC <br />TERMS FOB COaI Mine Revegetation TT <br /> PURLNASE <br />R <br />R <br />G/L ABL <br />O&1 ENCUMBRANCE <br />CC <br />SUGGESTED VENDOR AND ADDRESS NUYBER <br />O <br />DE <br /> ACCT NO ORG UNIT ACOT NO CODE AMOUNT <br /> 50917 0-00-091 10910 6301 000 <br />320 st <br /> VENDOR NUYBER , <br /> I hereoy certity loaf Ine supplies or services listed are necessary for the 9u<cesalul <br /> operation of Ih0 agenq and In! quantity requested is the minimum amount and fund <br /> <br />ZIP designated'is suHlcienl to cov same. % / <br />1 ~ <br /> <br />. <br />I <br />TERMS FOB l/ ,, <br />/ <br />/ <br /> l <br />J <br />BILL TO - Nema and Adtlreas /~ ~ ~ ~~ //' <br /> ~ _ \ AGENCY HEAD <br /> REQUESTING AGENCY -Name antl Address <br />Same as Requesting Age ncy Mined Land Reclamation Division <br /> 1313 Sherman Street, Room 215 <br />s'IIPTO-NamaendAtldreas Denver, CO 30203 <br />Same ds Requesti n9 Agency PERSON TO CONTACT (Onpinator of Rpueap TELEPHONE <br /> 866-3567 <br /> Larry Routten FAx <br />ITEM UNIT <br />NO. QUANTITY UNIT COMPLETE DESCRIPTION OF ITEM OR SERVICE COST AMOUNT <br />1 1 Projec Ref. Bid Number RN-GOAL-MINES-5 <br /> Hawk's Nest East Project <br />~'~ <br /> Western Slope Carbon, Inc., Permit No~ 9 <br /> C-31-016 <br /> This project is subject to advertising before <br /> final payment (C. R.S. 38-26-107). In <br /> addition, retainage will be held at 10%. <br /> All in accordance with specifications, <br /> drawings terms and conditions of the above <br /> bid and the attached BID SCHEDULE (Line item <br /> Price) sheet, which are made a part here of <br /> by reference. <br /> Delivery <br /> RegJReq'd: i <br />]95-57-06Y1~1 <br />White -Purchasing Copy Yellow -Accounts & Control Copy Pink -Agency Copy Goldenrod -Department Copy <br />