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~~ - q ~ (Page 2) <br />MINE ID # OR PROS(~PECTING ID #~ R >~~~e <br />INSPECTION DATE js ~O~-9~ <br />t..-r <br />INSPECTOR'S INITIALS~s <br />,(1 <br />T~-`- M ~ 3, /9 9 ~ ~:~~.~ '"`~.'`~ hem.-~-/ ~,~ <br /> <br />I 6 E Contact Address ec: ^ CE <br />R_G~~ ~k ^ BL <br />NAME ~ /f ~ ^ FS <br />OPERATOR ~ a"~k~-~-i ~-0-~.~.~'~ y---~ ^ HHMWMD (CH) <br />STREET 3 ~ ~ (~I~~ 4"~"~ V//1'~-~+~/(T~ ,1~ WQCD (CH) <br />CITY/STATE/ZIP ~~+!i W ' ~V ~ ~ ~ ^ OTHER <br />~~ <br />