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1 ` <br />• <br />Date of Service____________, 19___ <br />Person S?rved__Bob Asher <br />(Please print name and title) <br />Signa~ure------------------------- <br />(Parson served) <br /> <br />M ME LAND R A aTION DIVISION <br />BY- - ----- -- -- ---- <br />(a norized epresenta ~ e) <br />Jim Herron <br />Reclamation Specialist <br />---------------------- -------- <br />(Name and title - please print) <br />IM~ORi4~NT: PLEASE READ THE REVERSE SIDE OF THIS PAGE. <br />LO/79 C.i2.S. 1973. 34-33-123 <br /> <br />,,,, :. ,_ <br />