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3 <br />(Page <br />MINE ID # OR PROSPECTING ID # I"(-7~ I~-~CQ <br />INSPECTION DATE S-,S <br />• <br />INSPECTOR'S INITIALS <br /> <br />a 71l ,~ <br />a,~,' .~~b,~t5`~""' • ~.,w-~.,le a ,,,tee ,,~z~ ,~~~~~° ""~ .` <br />--- <br />I ~ E Contact Address <br />NAME <br />OPERATOR <br />STREET <br />CITY/STATE/ZIP <br />cc: ^ CE <br />^ BL <br />^ FS <br />^ HW <br />^ HMWMD (CH) <br />^ SE <br />^ WQCD (CH) <br />^ OTHER <br />