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Division of Reclamation, Mining, and Safety <br /> Fee Receipt for M2OOOO4O <br /> Medicine Bow- Routt National Forest USDA F Receipt#: 22673 <br /> Nate Davis Date: 12/16/2016 <br /> 2468 Jackson St. Permit: M2000040 <br /> Laramie WY 820706535 <br /> Check#1153 4300-MAFO Minerals Annual Fees $323.00 <br /> Linda S Schell USDA FS MB Supervisor Office <br /> 2015 <br /> Receipt Total: $323.00 <br /> Page 1 of 1 <br />