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Division of Reclamation, Mining, and Safety <br /> Fee Receipt for M1982129 <br /> L. Otto Goemmer Receipt#: 22500 <br /> Jacque Goemmer Date: 11/14/2016 <br /> P.O. Box 165 <br /> Permit: M1982129 <br /> La Veta CO 810550000 <br /> ;erg <br /> Check#1432 4300-MAFO Minerals Annual Fees $323.00 <br /> Goemmer Brothers LLC <br /> *FEE ONLY(Due 8/5/16) <br /> Receipt Total: $323.00 <br /> twe"ENO) <br /> !'RCCLAMA9'IONy <br /> MINI 4 FI STY-MINF- A►LS <br /> FE <br /> Page 1 of 1 <br />