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1 <br />DIVISION OF MINERALS AND GEOLOGY <br />CERTIFICATE OF SERVICE <br />PERMIT N0.: C-~ ~ -(~~-1 <br />C.O. NO.: <br />N.O.V. NO.: ~-q,~-~.~~ <br />I hereby certify that I served a copy of the foregoing NOTICE OF PROPOSED AMOUNT <br />OF CIVIL PENALTY on the operator therein described by (a)' personal service <br />upon the operator or its representative at Colorado <br />on OR (b)` by depositing a true copy thereof first class <br />postage prepaid in the United States mails at De ver, Colorado, addressed to the <br />operator at the address above, on 9 19GY /• <br />Certified Mail No.: <br />Return Receipt Requested <br />Signature of Person Served <br />if personal service <br />Print Name and Title <br />gnature <br />Print Name and Title <br />* ---- Check applicable method of service. <br />REQUEST FOR CONFERENCE <br />The operator above described hereby requests an assessment or settlement <br />conference as permitted by C.R.S. 34-33-123(8). <br />Operator <br />By <br />(Signature) <br />Date 19_ <br />5/90 <br />0311(f) <br />