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(Page 2) <br />MINE ID # OR PROSPEpCT, ING~-cID # 1q-I -O y ~ Z ~t <br />INSPECTION DATE Q - Jn / ~ INSPECTOR'S INITIALS~~ <br />Cv-zS Sin ~ e~4-~--~ v~-S (ws~1~ ~. ~,y~ ~ e. 't'r~L-0 <br />ct~c vro S } A'I '1~ ~-o~ / l0 ~P~C ~ Q~7 C~ ~~~~ ( <br />se~~,~ ~~ ~~sF ~e,GW ~ s P/7 _ TI~;S ,s <br />fi f ~o S~ `"~ G~-S <br />U,.P,y e_ Cm,,,, r• u a ~ c a~ `~v -r`~.,z o p , <br />I ~ E Contact Address <br />NAME <br />OPERATOR <br />STREET <br />CITY/STATE/ZIP <br />~ ~~~ ~c~,.. ~~~~ <br />cc ^ CE <br />^ BL <br />^ FS <br />^ Hw <br />^ HMWMD (CH) <br />^ SE <br />^ WQCD (CH) <br />^ OTHER <br />