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• 1 'C . <br />• <br />~ d t e o f S e r v i c e??~= ccrnber 4--- ~ I q 81- <br />person S?rv.4---------------- <br />---------------------------------- <br />(Plea;? orint name and titlel <br />Sidn3c~re------------------------- <br />(Porson served) <br />• <br />kIME•U te~vD RECL~.~dil'J`! 7IV[SI.ON <br />aY----------------------------- <br />(a~:norized representative) <br />Tom Gillis, Reclamation Specialist <br />(`ld me dnd titlo_ - please print) <br />I,M~ORie;~i: ptE;SE 4ce0 THE ~EVERSc SIDE OF iN[S ~eGE. <br />10/79 ~.it.~. 1a13, 34-33-123 <br />