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STATE OF COLORADO <br /> PURCHASE REQUISITION <br /> SUGGESTED VENDOR AND ADDRESS PURCHASE SUGGESTED VENDOR AND ADDRESS PURCHASE <br /> ORDER NUMBER ORDER NUMBER <br /> Colorado West Leasing <br /> 241 31 3/10 Road VENDOR NUMBER VENDOR NUMBER <br /> Grand Junction CO zIP 81503 ZIP <br /> TERMS 4 �Z <br /> FOB TERMS FOB <br /> I. <br /> DOC ID a CODE NO. <br /> DO 000 <br /> V ? � � A T P D 9D 4 ACT V TYPE <br /> UND AGENCY ORG SUB-ORG APPR CODE BS ACCT OBJECT SUB-OBJ REV SRC <br /> 2 7 0 P K 2 2 0 5 m 5 6 4 T 2 3 1 1 m <br /> SUB-REV PROGRAM GBL FUNCTION REPORTING CAT PROJ/JOB NO OFF REC ACCT <br /> mM N R C 2 0 5 E n <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 866-3567 Maggie Van Cleef <br /> FAX <br /> 832-8106 <br /> I hereby certify that the supplies or servIc d are c sary for the success r jont e agency and the <br /> quantity requested is the minimum amoun n fu de a d sfficient to cover sa <br /> Xj <br /> AUTHORIZED SIGNAT <br /> ITEM QUANTITY UNIT COMMODITY BER AND UNIT <br /> NO. COMPLETE DESCRIPTION OF ITEM OR SERVICE COST AMOUNT <br /> REFERENCE PRICE AGREEMENT q <br /> i <br /> 93 Maintenance/Coal Basin <br /> 1 40 Hours D7 Dozer, with oprator, per specs $ 77.00 $3,080.00 <br /> 2 40 Hours 966 Cat Loader, with operator, per specs 67.00 2,680.00 <br /> 3 40 Hours Tandem Dump Truck, with operator, per specs 38.00 1,520.00 <br /> $7,280.00 <br /> REQUESTED DELIVERY DATE <br /> 395-53-05-2141 <br /> WHITE-Purchasing Copy YELLOW-Accounts&Control Copy PINK-Agency Copy GOLDENROD-Department Copy <br />