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STATE OF COLORADO <br /> PURCHASE REQUISITION <br /> SUGGESTED VENDOR AND ADDRESS PURCHASE SUGGESTED VENDOR AND ADDRESS PURORDER CHASE <br /> NUMBER <br /> ORD <br /> NDOR NUMBER VENDOR NUMBER <br /> ZIP ZIP <br /> TERMS �L/ FOB TERMS FOB <br /> DOC !D T CODE NO. <br /> PV DATE AC T P D BUD FY ACT PV TYPE <br /> � 9 <br /> 3 4 ❑ ❑ <br /> UND AGENCY ORG SUB-ORG APPR BS ACCT OBJECT SUB-OBJ REV SRC <br /> 27 0 P RA 2 20 5 m 5 64 23 11 m �� <br /> SUB-REV PROGRAM GBL FUNCTION REPORTING CAT PROJ/JOB NO OFF R® <br /> M I N R C 2 1015 E <br /> BILL TO-Name and Address SHIP TO-Name and Address <br /> Division of Minerals and Geology Designated 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 n <br /> 866-3567 Maggie Van Cleef <br /> I hereby certify that th supplies se Pices listed are necessary r th su cessful operation FAX <br /> of the agency and uan r to is tha-minimum amount fu d ignated is <br /> sufficient to cove <br /> 832-8106 <br /> AUTHORIZ SIGNATU E <br /> COMMODITY NUMBER AND UNIT AMOUNT <br /> NO. <br /> ITEM ANTITY UNIT C PLETE DESCRIPTION OF ITEM OR SERVICE COST <br /> REFERENCE PRICE AGREEMENT # <br /> 93 Maintenance/Twin Pines Drop Structures <br /> 1 1 Job Construct drop structures, per specifications N/A $7,720.00 <br /> and per attached bid schedule <br /> REQUESTED DELIVERY DATE <br /> 395-53-05-2141 <br /> WHITE-Purchasing Copy YELLOW-Accounts&Control Copy PINK-Agency Copy GOLDENROD-Department Copy <br />