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Division of Reclamation, Mining, and Safety <br />Fee Receipt for M1979216 <br />Fremont County <br />Receipt #: 20762 <br />Date: 12/29/2015 <br />Permit: M1979216 <br />Payment Method Revenue Code'! <br />Notes n" <br />Check #111036 ( <br />4300-MAFO <br />Minerals Annual Fees <br />M-1979-216 <br />$323.00 <br />Receipt Total: <br />$323.00 <br />Page 1 of 1 <br />