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:HECK REQUEST <br />°NAME <br />`, <br />Division of Reclamation, Mining and Safety <br />DATE OF REQUEST <br />DATE CHECK <br />NEEDED <br />2/2/2012 <br />2/10/2012 <br />SS <br />1313 Sherman Street <br />ADDRESS <br />Room 215 <br />DATE CHECK TO SE <br />DATED <br />2/10/2012 <br />crry <br />Denver <br />Tax Rate/Area <br />$ 791.00 <br />STATE <br />CD ZIP CODE /VENDOR NUMBER <br />V 80203 <br />= <br />OMMENTS TO <br />BE PRINTED ON CHECK M- 1997-007 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I I I I I <br />❑ RETURN To Karen Jackson Loc• 668 <br />❑ REGULAR MAIl. ❑ SPECIAL HANDLING INSTRUCTIONS <br />Business Unit <br />Object <br />Subsidiary <br />AMOUNT / DIST. <br />Subledyer <br />Sub <br />Type <br />Tax <br />Rate/Area <br />Taxable Amt <br />Aca d Tax <br />Amt <br />Asset ID <br />Additional Information <br />166802 <br />5275 <br />$ 791.00 <br />Bijou day mine fee <br />1 <br />�- it* <br />tifitelZ ,�, <br />i <br />$ _ <br />$ - <br />d '• LOYEE <br />REQUES <br />" <br />Karen Jackson <br />APPROVED - AUTHORIZED SIGNATURE <br />APPROVED - ACCOUNTING DEPT <br />ACME BRICK COMPANY <br />