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<br />MINE ID # OR PROSPECTING ID #: M -5 ~ `Iq4
<br />INSPECTION DA -E: ~- 7-`~ ~ INSPECTOR'S INITIALS: ~ D
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<br />I & E Contact Address
<br />NAME: f'/g ~~ u L.r e K~ Gaerre r-,asocc. e2
<br />OPERATOR: C-L~2SrQ2nJ ~/G31LG' .~U,Tµe~2N /NC
<br />STREET: / S~7Q LJ /~ rN ,4ye~ue.
<br />CITY/STATE I ~ (~~,SUQ/Z ~ p g6,~7~
<br />C.~~TIFIED r~,~it.- Bqs
<br />REI~URN RECEIPT REQUESTED
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<br />^ FS
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