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Division of Reclamation, Mining, and Safety <br /> Fee Receipt for M1981158 <br /> Forest Lakes Metro District Receipt#: 22809 <br /> Dale Kortz Date: 01/19/2017 <br /> P.O. Box 440 <br /> Permit: M1981158 <br /> Bayfield CO 811220440 <br /> MethodPayment Revenue Codei e • • By • • Amount <br /> Check#023876 4300-MAFO Minerals Annual Fees $323.00 <br /> 2017 <br /> Receipt Total: $323.00 <br /> Page 1 of 1 <br />