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SPATE OF COLORADO <br /> PURCHASE REQUISITION <br /> SUGGESTED VENDOR AND ADDRESS "� PURCHASE SUGGESTED VENDOR AND ADDRESS PURCHASE <br /> ORDER NUMBER ORDER NUMBER <br /> AZCO Construction <br /> 2055 H 50 VENDOR NUMBER VENDOR NUMBER <br /> Penrose CO ZIP 81240 ZIP <br /> TERM/STax ID #84-1023014 FOB TERMS FOB <br /> d. <br /> P 9 BUD--4 [] [jYPE <br /> . <br /> UND AGENCY ORG SUB-ORG APPR CODE BS ACCT OBJECT SUB-OBJ REV SR� <br /> 2 7 0 P K A C C C 8 m 1 2 2 Hm 2 3 1 <br /> SUB-REV PROGRAM GBL FUNCTION REPORTING CAT PROJ/JOB NO mOFF REC ACCT <br /> m MN RC a 1 11 1" 1 1 1 1 <br /> BILL TO-Name and Address SHIP TO-Name and Address <br /> Division of Minerals and Geology, Desingated Job Site <br /> 1313 Sherman St. , Rm. 215 <br /> Denver, CO 80203 <br /> REQUESTING AGENCY-Name and Address TELEPHONE PERSON(S)TO CONTACT <br /> Same as bill to (303) <br /> 866-3567 Maggie Van Cleef <br /> AX <br /> (303) <br /> 832-8106 <br /> I hereby certify that the supplies or services dare cessary for the successf oper lion f agen and the <br /> quantity requested is the miromum amoun n u d de at is icie ro cov sa <br /> �,AUiHORIZED SIGNATURE <br /> I COMMODITYNUMBER AND UNIT <br /> No QUANTITY UNIT COMPLETE DESCRIPTION OF ITEM OR SERVICE COST AMOUNT <br /> REFERENCE PRICE AGREEMENT # <br /> s <br /> { <br /> {Trinidad Basin Mining Company <br /> Permit #C-81t-048 <br /> Emergency Sediment Pond Repair <br /> 1 1 Job iExcavate embankment failure, install CSP N/A 4,385.00 <br /> land anti-seep ring. <br /> 2 80 Ln. FW 2-inch diameter, 16 gauge CSP $12.00 960.00 <br /> F <br /> 3, 1 Each {Larger anti-seep ring, if required N/A 50.00 <br /> TOTAL K5395.00 <br /> 3 <br /> i l <br /> { REQUESTED DELIVERY DATE <br /> � { i <br /> 395-53-05-2141 <br /> WHITE-Purchasing Copy YELLOW-Accounts&Control Copy PINK-Agency Copy GOLDENROD-Department Copy <br />