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l~ <br />s - <br />• • <br />Date of Service____________, 19___ <br />Parson Served Larry_Reschke__ <br />- - - - - -- -------M1I1JD9 _E1L47DE~r -_ _ _ _-- <br />(Please print nar'e antl title) <br />• <br />,MIPIED taNO RECLaMai[ON DIvISION <br />gY-------------------^-- °--- <br />(authOriZetl representative) <br />Sian.ac~re_________________________ James Herron, Reclamation Specialist <br />------------------------------- <br />(P?rson served) (NaTe and title - please print) <br />IM?ORTaNi: PLEaSE aEaO THE REVERSE SIDE OF THIS PaGE. <br />10/79 Q.R.S. 1973, 34-33-123 <br /> <br />