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<br />((P~a/ge 2)
<br />MINH ID # OR PROSPECTING ID # NI ~~ v~l
<br />INSPfiCTION DATfi - - ~ INSPECTOR'S INITIALS
<br />9 -r-a ~
<br />~,-0~5 r vl J ~'1^-~O~" ~4`- So, i s J k S '1" a~ c-v-a- `T~--
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<br />be,e.(.- ~ Jew ~~~ ~~n, `` ~ ~ I ~`` .``~ w 1-+~ ,tie.~.,~ -R ~nf I . (,J ~ iII'S
<br />~+~" 111 ~ r ~ ~-o '~'`~°" D w ~J 171 e, .,~.~ o,..~ v d- ~`~..~ ~; 1 f
<br />Ne,a.r ~r vow--11. A s~r~~-p`'' (~'{', 1`~"- ~`a-fi `j2E.r^ ~n-S ~{~
<br />W" 4 s ~pr~e, ab ~ ~ "~ C Q~l~' C`~ ~ , I 1 ~, t -t'~
<br />3 ~ ,,:.~e-,~ dl~-an.- A.wd -+'~.~e-~- `~O `~ Nom- {~-~e.,.~L{~-a,~ ~ Q
<br />~0 C' b ev,n'~ ~ 0-1.. S`~"~--i'~a-~-- ~ S ca~-r h c..~o~w i ~.. S~n~iwX.
<br />-n..,k- i I..a( o~ e 1-`,,l~c,.~ 5 A~ v~,~~,p~S ~,~A.7~~o1,~ P,r~-s u r i r,~-9 T lndn 7~"L
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<br />~- `~ ~-I ~ ~~t- ~~~.-~.~.~ S ~ sue--- ~ ~ „~-~S
<br />0 4i ser.re,~ -~to lr,a..e.- P°'~O~ '^'°~~ ~ ~' (+ _ 1 I
<br />~,, rr~ ~z.~re.d p-..,.dt sng~Q- ',ti `e-1,-y~~ ,.e~ ,MO~~-~-~1 ~a-cl ~ S,/P~ ~ ~I I ~ a--~~-0
<br />~'~L 0.G(,' ~iS ~ o~ (7~~ ~ \ ~ OI"~ ~^~a ~ iJO~YR.T°~' ~^ltS~
<br />Z 6 E Contact Add1reas 1 , 1 cc: E u 1( r~/' ~ (y~~+(~~ 1
<br />NAME /M+ f. _lo~~ ~TAv--I''a/I-a.~o{{w //;; `{ nn ^ FS ~1/l/~~^~ 5~c \~'`~\~W
<br />OPERATOR C,,-,DDI C~P~ ~ V l r '}oY lCo lr'1i Mi..k~. ~j, ^ HHMY7NID (CH)
<br />[~ p~ ^ SE
<br />STREET ~~ O~.`70~~ \~ ^ WQCD (CH)
<br />CITY/STATE/ZIP ~1 C~~Y I~G v~ ~ O ^ OTHER
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