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STATE OF COLORADO <br />PURCHASE REQUISITION <br />I SUGGESTED VENDOR AND ADDRESS I ~ PURCHASe I SUG GESTED VENDOR AND ADDRESS ,~„P~RCHASo <br />VENDOR NU MRER 1 I VENDOR NUMBER <br />ZIP I 1 ZIP I 1 <br />(TERMS <br />(DOC ID <br />FOB (TERMS <br />FUND AGENCY ORG SUB-ORG APP( <br />4 6 2 P A C C C 8 m 1^ <br />SUB-REV PROGRAM GBL FUNCTION <br />m M N R C <br />BILL TO -Name and Atltlress <br />Division of Minerals and <br />~zd nv- cc <br />'~i-ama c i o rl o i Y <br />" <br />~ Geology <br />i S i o r ~ <br />, <br />T, <br />c <br />1313 Sherman Street, Room 215 <br />Denver, Colorado 80203 <br />REQUESTING AGENCY - Nama antl Atltlress <br />Same as Bill To <br />or serv ices lisfetl <br />amount and fund <br />CODE NO. <br />FOB <br /> BS A CCT OBJECT SUB-OBJ REV SRC <br />1 <br />J ~ 2 2 m <br />ORTING CAT PROD/JOB NO OF <br />F <br />RE <br />C <br />AC <br />T <br />C <br /> II ~ <br />~ <br />~ <br />II <br />II <br />II <br />~I <br />SNIP TO -Name antl Address <br />Designated Job Sites, Per Specs <br />TELEPHONE <br />866-3567 <br />FAX <br />832-8106 <br />the agency and th <br />PERSON(S) TO CONTACT <br />AUTHORIZED SIGNATURE <br />ITEM I pUANTITY UNIT COMMODITY NUMBER AND UNIT I AMOUNT <br />NO. I COMPLETE DESCRIPTION OF ITEM OR SERVICE COST { <br />j REFE REN CE PRICE AG REE MENT # <br />Ref. Bid Number RN-MINES- 302 <br />1 ~ 1 Rroject Blue Flame Coal Revocation Project N/A <br />Permit C -81-053 <br />L & L Energy <br />is project is subject to advertising before <br />nal payment (C.R.S. 38-26-107). In additio <br />tainage will be held at 10%. <br />11 in accordance with specifications, drawing <br />erms and conditions of the above bid and the <br />ttached BID SCHEDULE (Line item Price) sheet, <br />hich are made a part here of by reference. <br />DELIVE RV DATE <br />WHITE-PUrchasiig Copy YELLOW-A000U ntsB Cen[rol Copy PINK-Agency Copy GOLDENROD-OepaNmem Copy <br /> <br /> <br />