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A ~ p.,..,~ (Paeg re <br />.MINE ID # OR PROSPECTING ID #pl~1 -O V -~ T~ //~~ <br />INSPECTION DATE LQ ~~~ / ~ INSPECTOR'S INITIALS~~'` <br />Q~ I ` ~~ ua5exvwrlurvs e~ I I n <br />'n.C~t U'ec,~u.~c°d w (T(.-. ~° +'o s (B~-~ e L ~0 ~ °f / <br />r~ s ~ -Fa/ so ~ /e~ ati-~-.~ v~Q h -- -~t~ S o ~~ 1~~~ o~ c^-~~ S <br />17rt,1 ~~''15 ~~p~~2~3 w~~1-~SSPS~ 'te5cue~Y,~ ~as/t <br />21~ ~+^1 I ~ t~ S fin cP_ SS ~-~ ~~f 1 S V~a~.l'~ ~S l.~ IS~ / •~ <br />-I`~"-'~~ IB~//. ~)~. '~`-v~a~~c..,i~ S o^t~ / Vim. ry r~..~ So i I <br />~o,retr5 PGA--fit" cL eo-k-~1-a / a..v-e i ~^4 c. ~~. ~e.. ~-e ~ S <br />a ~ , sub ~ ~-F-~./J b~.~(,~ --~...~ ~- ~fi , e- f C ^ - <br />CevCr ~ v er r2"~ (~^~cC c~/~~. ~e, v2-v-Sc.~ S `'~` 2 0~ Y- / "1'~,I ~ cF~' <br />~ ~c~ p~Q~~ c ~C 5 ~"'~e S 1 N N 1 ~1 C~ ~.pa (~.ea~... M Y~-j-~j-t- <br />Ire-~"O r-~~ S 1~o~-t' e dis ~©l s ~ ~e s-~~- ~ ; ~; ~s~ - , <br />0.~ ~~n ~~~ ~-.-o'~m-l-~ e~ a` r~ I'''~" V~&~'/-Gu ~FIc6'~ ,y <' <br />1r-e~U t~ ~ ~ ~n~.(~~e ~ . ~ , ~ ~ ~-`a- s e ti P ed' -F-n b eY}, <br />~~~ ~ ~ e ~ V' '1~ I ~e ~ t v 1 S ~ ai c.~., ~ ~ ~ g ~~Jl <br />i <br />b~i~ s s+~-~e y-~ ~ ~ side ( ~-~- ~-+„~ <br />~O Y"~-Q-~--T `v'im V `~ ~` c' `w"~4J`S Q~ ~'^'~ L° >. ~• ~ Z <br />I & E Contact Address cc: ^ CE <br />^ BL <br />NAME ^ FS <br />^ HW <br />OPERATOR ^ HMWMD (CH) <br />^ SE <br />STREET ~WQCD (CH) <br />^ OTHER <br />CITY/STATE/ZIP <br />