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, f . . , <br />• �r�'V✓ t/i..�-- <br />.� is�to-aa <br />.pril 1992) <br />UNITEI7 STATES <br />DEPARTMENT OF THE II�iTERIOR <br />BUREAU OF LAND MANAGEMENT <br />�COPY WORK REGIUEST <br />Reference Number <br />�6 �r :� ? Ci "� � <br />Date � � � <br />� <br />FOR BI.M USE ONLY <br />� il� <br />�ddrest,{inctudezip code) (Optianal} PREPAYMEf�iT R�QU{RED <br />��� S��`� Paid by: ❑ t� Q M�ey Order S <br />, l3 ��'��� 5��1 — C�� (Pa��able ro Deparrsiart rlre r,rte�orBl.,�r) <br />� � ��� � `TC�I s <br />� ` � <br />'elephone (irrclude area code Credit Card ❑ VISA ❑ MasterCard��X' $ O <br />� � <br />� Wai6ag ❑ Pidc up � i DAL��aouat Fio� �� ����(�Balance S <br />DOCIJMEN£ OR REG`aRD {TYPE} �R� QUAN'iI7'Y P�C TOTAL <br />� (� . . <br />�,.J <br />� �� . <br />� 4 ..�j 1� � i,� �1 "� c.�c..l'' � <br />�-�-I� <br />� <br />.S� u <br />Z, .G ci <br />z.Zd <br />/ o s �" <br />►verpayment o€ $ to be refnnded by ��� �� � , Grar� Totat $ <br />United States Treasury check - atlow 30 days B�M 0��, r 5�,S <br />New $ <br />Refunds of Less Than $1.00 Upon Request Only �� ��� <br />�— <br />.emarks: <br />