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Division of Reclamation, Mining, and Safety <br /> Fee Receipt for M1991081 <br /> Sam Keeling Receipt#: 22232 <br /> Sam Keeling Date: 09/23/2016 <br /> P O Box 361 Permit: M1991081 <br /> LaVeta CO 810550000 <br /> MethodPayment Revenue Code • • • Amount <br /> Check#1059 4300-MAFO Minerals Annual Fees $323.00 <br /> Due 9/23/16 <br /> Receipt Total: $323.00 <br /> Page 1 of 1 <br />