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P A Y E E DETACH THIS STATEMENT BEFORE h +SITING <br />1 ~v~nthias Concrete, Inc. <br /> <br />DATE AC COUNT OR <br />INVOICE NO 1 <br />DESCRIPTION AMOUNT DISCOUNT OR <br />DEDUCTION <br />NET AMOUNT <br /> .J7 ~O~YM~ ~ ~ ~ 7- I~0 ~. <br />0 <br />EMPLOYEE'S <br />NAME <br /> <br />w~aii~ias Conc;eto, Inc. ~~ ' <br />PAY PER100 HDQRS RATE GRO55 NET <br />ENDING C[D wrtr <br />EARNINGS si aiC wirN EARNINGS <br /> ~ i ~ + <br />T+r i+n PAID <br /> I I~F~J~ I_._] <br /> <br />EMPLOYEE: THIS IS A STATEMENT OF YOUR EARNINGS AND DEDUCTIONS FOR PERIOD INDIC4TE0. KEEP THIS fOR YOUR PERMANENT RECORD <br />MINED LAND~RECLAMATION ISION N~ 2955 <br />1313 Sfirrman'Street'Room y13 <br />Denver, CO 80203 oArE (` ~~ Ts~ <br />rn(303) ee8,,66-3567 <br />RECENEO FFIOM(' 1Q~r~+ n ~'h Ct Il0'~'1 ~ln"(Y ~y`~J~~ <br />THE SUM OF ~ ~©WBOILARS $ ~J~JLJ• <br />~ ~ ~cw~+ <br />FOR ~C (~ ctt <br />AMOUM OF AC UfVT...... $ " 1 1tQ01N ~OL(! <br />4MOUtJT PAID ................ $ (J ~,44~~ <br />BALANCE DUE. .$ B <br />i <br />