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MINED LAND RECLAMATION DIVISION <br />CERTIFICATE OF SERVICE <br />N.O.V. N0. C-II5-004 <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 , <br />Colorado on 19 or XXX b * by depositing a true <br />copy thereof first c ass postage prepaid in the Uni'~ States mails at Denver, <br />Colorado, addressed to the operator at the address above, on , <br />19 <br />Certified Mail No. P 652 676 248 <br />K~ , l~' ~.t,~.`1 <br />°~ Signature <br />Gregg_ R. Squire <br />Name Printed <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 /> <br />~/j /~, Operator <br />Sig ature <br />Date /~~ ii ~ ~ ~~ I i 19 <br />(1/83) <br />Doc. No. 251 <br />