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(Page 2)
<br />MINE ID f! OR PROS PECTINGp IUD k m- ~(7-r24-4
<br />INSPECTION DATE ~ -II' ~O INSPECTOR'S INITIALS_~
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<br />I 6 E Contact Addreee
<br />NAME
<br />OPERATOR
<br />STREET
<br />CITY/STATE/ZIP
<br />cc: o ce
<br />O BL
<br />O FS
<br />O HW
<br />O HMWMD
<br />0 SS
<br />O WQCD
<br />O OTHER
<br />(CH)
<br />(CH)
<br />
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