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<br />• <br />~'~ <br />Ddt2 of Service_Auqust 7,__-~ )q-81 <br />person S?rved__vance-Mills_--__ <br />------------------- -------'---- <br />(Please drint name and tit12) <br />'+["lED L~vD 4ECLaNCT10'+ 7iVISIJ•v <br />3y---~ ---- S~'',~~-_-- <br />(au *.norized represg'lta ti v~?) <br />SIOn3LJre - Michael 5. Savage, Reclamation Specialist <br />(PArSdn Served) (^la re and title please print( <br />IM°DRTis.VT: PtEaSE 4EoD THE REVERSE S[DE OF itilS ~oG'c. <br />l0/79 C.R.S. 1973. 3a-33-123 <br /> <br />