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<br /> <br />Date of Service____________, 19 ___ <br />Person S?rved__ Bob_ASher <br />---------------------------------- <br />(Please print name and t~t1e) <br />Signature------------------------- <br />(Porson served) <br /> <br />MINE CeND RECIeMaTION DIVISION <br />' BY- -1-- ~ ` ----------------- <br />(a hOriZed fep esentative) <br />Jim lle rron <br />Reclamation S ecialist ' <br />{Name and title - please print) <br />IMPORTaNT: PLEeSE REaD THE REVERSE SIDE OF THIS PoGE. <br />l0/79 C.R.S. 1973, 3a-33-1Z3 <br /> <br />