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' • ((Page 2) • <br />~ Ml~ic^ID ~ OR PROSPECTING ID #:om''~n~~.~y <br />INSPECTION DATE: I ~ ~S f I $ INSPECTOR'S INITIALS: <br />OBSERVATIONS <br />~M~t d~,~~~ -}~ -.~n~,~,~.~.t~-~- -~na~ N~'~• ~ f a~.vs fan <br />~~. <br />/ 5 o.r^ ~ S ~ a ~t ( uM ~ C9,l~,ct,~,/~ ~k~1.~,0 wenSL ~ eke • <br />~~~~~ . <br />~-~~ <br />~°~ - ~.~.~.~ M ~,~ g a,•,,,,~ - ,,mss,,,, ~,t,,,,,,,~~ tit,Y,,,,,,y.e~, , <br />~ ~ <br />I & E Contact Address <br />NAME: ~n~.• ~ c nAtiQ.Q~A' <br />OPERATOR: ~ C ~ ~}iI q <br />STREET: ~ ' (`~ ~~/`~ ~ ` L('I^~ <br />CITY/STATE/ZIP: F~ Cc~ <br />~r- r--fo~,~h~ <br />cc: b1 C~ S <br />^ BL <br />^ FS <br />^ HW <br />^ HMWMD (CH) <br />^ SE <br />^ WQCD (CH) <br />^ OTHER <br />