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STATE OF COLORADO <br /> rfURCHASE REQUISITION <br /> PURCHASE AGENCY NAME P R NUMBER <br /> ORDER NUMBER Minedan eC amation Div <br /> SUGGESTED VENDOR AND ADDRESS E <br /> WnC nlQ( F/V DATE FUND ACT CD AGENCY NUMBER ' <br /> CJ��7 �d �S IK(.12ws VENDOR NUMBER - 1402 PKA <br /> >- v b2adurdibld <br /> �rl C'0 ZIP gOv-1v COMMODITY CC <br /> TERMS FOB Inactive Mine Reclamation 71 <br /> PURCHASE /' ABL ENCUMBRANCE <br /> SUGGESTED VENDOR AND ADDRESS ORDER NUMBER O ORG ODE AMOUNT CC <br /> 561 -GQet--_ 165E' 2820 � ��' 387 <br /> VENDOR NUMBER <br /> 5, <br /> Program: MNRC <br /> I hereby certify that the supplies or services listed are necessary for the successful <br /> operation of the a ncy and the quantity requested is the minimum amount and fund <br /> designated is suH i nt to cover same. <br /> ZIP <br /> TERMS FOB <br /> BILL TO- Name and Address <br /> Mined Land Reclamation Division AGENCY HEAD <br /> 1313 Sherman Street, Room 215 REQUESTING AGENCY-Name and Address <br /> Denver, CO 80203 Mined Land Reclamation Division <br /> 1313 Sherman Street, Room 215 <br /> S'IIP TO-Name and Address <br /> Denver, CO 80203 <br /> PERSON TO CONTACT(Originator of Request) TELEPHONE <br /> Designated Job Site (per specs) Maggie Van Cleef 866-3567 <br /> FAX <br /> ITEM UNIT <br /> NO. QUANTITY UNIT COMPLETE DESCRIPTION OF ITEM OR SERVICE COST AMOUNT <br /> Ref. Bid Number RN-MINES- 270 <br /> 1 1 Project %Coal Basin Mined Land Reclamation Project N/A 76r3V <br /> This project is subject to advertising before <br /> final payment (C.R.S. 38-26-107) . In <br /> addition, retainage will be held at 10%. <br /> All in accordance with specifications, <br /> drawings terms and conditions of the above <br /> bid and the attached BID SCHEDULE (Line item <br /> Price) sheet, which are made a part here of <br /> by reference. <br /> 6252F <br /> Delivery <br /> Req./Req'd: <br /> 395-53-05.2141 <br /> White-Purchasing Copy Yellow-Accounts&Control Copy Pink-Agency Copy Goldenrod-Department Copy <br />