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y <br />• (PIa/ge ~) • <br />MINE ID # OR PROSPECTING ID6 #_/n"/' a " " ~~`~ r <br />INSPECTION DATE f// / ~/- / / / 7 y INSPECTOR'S INITIALS ~J C <br />// SERV TIONS // / ~ J < I ~ <br />%l~~~ ma~4;'<„Q r,.wvt I'2ww~ec~~bSo~9;~ <br />%/~ oi'! W4S Cleyle~C y~O /g~4~ W¢t%( r~.l~•'~g ~1Y17 ~"~//,~~ <br />9itG( 7/~G .So// ~_~INQQG~ cGt~l9'tS//~~ Jr11Pa~/~ J`zr ~j0r[~d;D•+J ,4(~/~'~ <br />C7J ~ S ~ 2Z,tC/ /l~r~e3'~ `~ • b ~`1~i"e ~ Jo ~ c~S Cdw l~ `/~ / ' /~cs( <br />a r~a$ua / ~y l 7TH 9'eO~srex, ~MrrG we S /a/~~ al V 7r+ ,y 4~c <br />' -r- ,/ / Ci'GJ G <br />~e-/ U4u.GCPiI CYCu-) i ~B/f~J ~C~~* 2~9/~. `S'~J~~ <br />~4~ PC- l/iyJ~"~~ (/JI !/I~f ~I+'LU' ~~( ~//~-N ~,L`Yi; l~~A`~ (i~ry/J /Cl~ <br />I Qa CLl U~/ GGf ?+jkcf~ C/7 F~~ ' ~ wi /' ` "l' `+N'~ /~/frU • /%J ,f, <br />v 7`~r ~7T~2J r' <br />~7~~-- ~; ~ ~ s, o.~ ,,~ ~,~~ C~nr,~r eu~ ~errt~ aaG~ 7v!'r~ <br />en s4•~ ~~ ~7~-~4~ ~~ t~ s~~' 1 / / <br />c~ usl~ -~ ~ e~~ ~~ IN~LYVS~/ <br />/~ /0 3v ~rsJ ~~~ <br />K s ~° <br />;~.,~all~ wyf P~~~ ~ac~~..z ~ P ~-~-- ~,I'l/nom <br />0~2-- csa Nc- ~4v1 CX,~ ~ ° /'al ~ i ~ P~(''C~ S'~ // +" <br />r,J ~ ill o ik T ~ o u~ 7U 1-''~- (~ L ~~YJdN N t~ W "o <br />J/~e.~ :,.lcr~ oL SC~1 / <br />.~+q ~c..l'~ ~J'4,rc_ ( ~~1~, // 'rr~j cre.~S <br />~JJ ~//~I/,S~J~ us ~~ ~~~~~ ~3'eq~ w~~s gCd~ ~-Dr~~~~ `'` <br />;a,J'lall wr ~~ o!J', ~ rAI~J~c~./ .r.s~ w, '~ Q c ~ ~Ys.~ry ~~(`' c+~f' s~a.~i; / <br />Cre.-JS Ire- neGe~'si~~ 4"~ MSR~ farC ~ (/~a~rJi'r.~ ~J 717~~ ~'''~WS,S <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 />