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ELBERT COUNTY PAYMENT REQUEST <br />PUBLIC WORKS DEPARTMENT <br />P. O. BOX 116 <br />KIOWA, CO 80117 <br />DATE July 10, 2013 <br />TO: <br />State of Colorado <br />The Division of Reclamation, Mining and Safety <br />1313 Sherman Street - Room 215 <br />Denver, Colorado 80203 <br />PLEASE CUT A SEPARATE CHECK <br />VENDER CODE <br />SPECIAL INSTRUCTIONS <br />MINLA <br />PLEASE RETURN CHECK TO PUBLIC WORKS <br />ACCOUNT NO. <br />INVOICE NO. <br />DESCRIPTION <br />QTY <br />AMOUNT <br />020 - 815 -5404 <br />20010102013 <br />Allison Pit M- 2001 -010 Annual Fee <br />$ 791.00 <br />Justification: <br />Upon signing I acknowledge Elbert county receipt of all goods per attached invoices <br />ELBER7 <br />CULIYI'1'.. . <br />Payment Request <br />$ 791.00 <br />Person requesting Purchase Order (Signature) Date <br />Department Head Approval (Signature) Date <br />