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<br /> <br />Jdt2 of Servire__ August 7,__~ Lq_81 <br />Gerson S?rve4__ Vance Mi1Is <br />W!"lEJ LANG REC C•MaTIO"! OI'JISI:7N <br />/ cJ ~1 <br />3y-- ------ ------ <br />(dutnOri2etl repre nta ti ve) <br />(Pled ie print na~+e a~tl tint) <br />Signat~re_____ <br />(~°rSJn Servetl) <br />Michael .S. Savaye, Reclamation Specialist <br />(Vale 3ntl title - please print) <br />I4~pi2T6NT: PLEASE READ THE REVERSE SIDE OF TH[S SAGE. <br />LO/79 C.R.S. 1973. 34-33-123 <br />