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<br /> DIVISION OF MINERALS AND GE(tiLOGY N ~ 3 8 0CC9 ~~ <br />~p DATE 1~ 19_y1 <br />RECEIVED l I ~ ~ a (~' ~5 <br />FROM u tel. <br /> OLL4RS <br /> ^ CASH <br />~ ~~~~ ~~ ~?~~~ O M~pCK <br />FOR~Q <br /> ~ <br />AMOUNT OF A OUNT.. ........$ <br />~~. <br />AMOUNT PAID ......... ...... ..$ <br /> BAINJCE OUE .................. $ BY <br /> <br />