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' ~ 4 ' (Page 2)
<br />MINE ID # OR PROSPECTINNG ID # (,~\- AO ~[~~I-~
<br />INSPECTION DATE \Ir7.~ ` ~ -I INSPECTOR'S INITIALS_~
<br />OHSfiRVATIONS
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<br />I 6 E Contact Address
<br />NAME
<br />OPERATOR
<br />STREET
<br />CITY/STATE/ZIP
<br />cc: ^ CE
<br />^ BL
<br />^ FS
<br />^ HW
<br />^ HMWMD (CH)
<br />O S6
<br />^ WQCD (CH)
<br />^ OTH&R
<br />
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