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STATE OFCOLORADO <br /> PURCHASE:REQUVd TI. N <br /> SUGGESTED VENDOR AND ADDRESS PURCHASE PURCHASE <br /> GGE ED VENDOR AND ADDRESS ORDER NUMBER <br /> AZCO Construction <br /> 20,r r) 11 S0 VENDOR NUMBER VENDOR NUMBER <br /> Penrose CO ZIP 81240 ZIP <br /> TERMS Tax ID #84-1023014 FOB TERMS FOB <br /> DOC IR.. < CODE: . <br /> ; , ` S <br /> VD E A CT PRO MDF ACT n <br /> YPE <br /> Ij ` ❑ • <br /> l <br /> UND AGENCY ORG SUB-ORG APPR CODE BS ACCT OBJECT SUB-OBJ REV SRC <br /> 2 7 0 P K. A IC IC I C 8 I m 1 2 2 I I , 1 1:] 2 3 1 m <br /> SUB-REV PROGRAM GBL FUNCTION REPORTING CAT PROJ/JOB NO OFF�REC ACCCTT <br /> ELI I MIN I R C <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 /> (30.3) <br /> C._ 832-8106 <br /> I hereby certify that the supplies orservices d ar ecessary for the successf oper tion f agenc and the <br /> quantity requested is the minimum amoun n u de at is ticie to cov sam - .. <br /> �- AUTHORIZED SIGNATURE - <br /> ITEM - - COMMOD Y NUMBER AND _ } UNIT <br /> NO. QUANTITY UNIT COMPLETE DESCRIPTION OF ITEM OR SERVICE COST ? AMOUNT <br /> REFERENCE PRICE AGREEMENT # <br /> €, . . :Trinidad Basin Mining Company <br /> Permit #C-81-048 . <br /> 'Emergency Sediment Pond 'Repair. <br /> 1 1 } Job . :Excavate embankment failure,. install CSP N/A $4,385.00 <br /> : and anti-seep ring. : <br /> 2 80 € Ln. Ft12-inch-diameter,- 16 gauge CSP $12.00 960.00 <br /> � I <br /> 3 .1 Each Larger anti-.seep ring, if required N/A 50.00 <br /> TOTAL $5395.00 <br /> { <br /> REQUESTED DELIVERY DATE <br /> 395-53-05-2141 - <br /> WHITE-Purchasing Copy YELLOW-Accounts 8 Control Copy PINK-Agency Copy GOLDENROD-Department Copy <br /> II <br />