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<br />MINE ID # OR PROSPECTING ID # ~ - ~] 't~ _ G~~ ,~
<br />INSPECTION DATfi %/ ~ 5'~/ INSPECTOR'S INITIAL
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<br />I & 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 />^ SE
<br />^ WQCD (CH)
<br />^ OTHER
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