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� STATE OF COLOAADO <br /> z � ���� PURCHASE REQUISITION <br /> SUGGESTED VENDOR AND ADDRESS PURCHASE SUGGESTED VENDOR AND ADDRESS PURCHASE <br /> ORDER NUMBER ORDER NUMBER <br /> DIRT-N-IRON <br /> 1417 326 RD VENDOR NUMBER VENDOR NUMBER <br /> SILT COLORADO ZIP 81652 ZIP <br /> TERMS TAX ID# 522-31-6989 FOB TERMS FOB <br /> DCC tD CODE NO. <br /> � ,J �ia av <br /> PV DATE T PRO BUD FY ACT PV TYPE <br /> a 9 3 <br /> FUND AGENCY ORG SUB•ORG APPR CODE BS ACCT OBJECT SUB-OBJ REV m 1 0 8 <br /> SRC <br /> ��2 7 0 P K A C C 8 1 2L� 8 2 0 <br /> SUB-REV PROGRAM GBL FUNCTION REPORTING CAT PROJ/JOB NO mOFF REC ACCT <br /> ED M N I R C I I I I I I 1 1] 1 1 1 1:] 1 1 1 1_ I I 1 1] 1 1 1 1:] <br /> BILL TO•Name and Address SHIP TO-Name and Address <br /> Mined Land Reclamation Division Designated Job Sites, Per Specs <br /> 1313 Sherman Street, Room 215 <br /> Denver, Colorado 80203 <br /> REQUESTING AGENCY-Name and Address TELEPHONE PERSON(S)TO CONTACT <br /> Same as Bill To 866-3567 MAGGIE VAN CLEEF <br /> FAX <br /> r <br /> G <br /> /1, 832-8106 <br /> I hereby certify that the supplies or services listeO ark n esQQQary for the succes ul oper io of�he agency and the <br /> duantity requested is the minimum amount and fu d sig ateq�j s sufficient to c r me _ / <br /> r <br /> AUTHORIZED NATU <br /> ITEM QUANTITY UNIT COMMODITY'NUMBER AND UNIT <br /> NO. COMPLETE DESCRIPTION OF ITEM OR SERVICE COST AMOUNT <br /> REFERENCE PRICE AGREEMENT # <br /> Ref. Bid Number RN-MINES- 302 <br /> 1 1 Project #1K�Xl £ X �(AID(X (XtY�t� 11 (D�X�tB(��I� N/A $24,000.00 <br /> L & L Energy/Blue Flame Revoked Site <br /> Permit No. C-81-053 <br /> This project is subject to advertising before <br /> final payment (C.R.S. 38-26-107). In addition, '; <br /> retainage will be held at 10%. <br /> All in accordance with specifications, drawings <br /> terms and conditions of the above bid and the <br /> attached BID SCHEDULE (Line item Price) sheet, <br /> which are made a part here of by reference. <br /> 6252FREOUESTED DELIVERY DATE <br /> I <br /> 395-53-05-2141 <br /> WHITE-Purchasing Copy YELLOW-Accounts&Control Copy PINK-Agency Copy GOLDENROD-Department Copy <br />