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<br />Dace of Service__Auqust 7,__, !q 81 <br />~2rson S?rv_d___ Vance Mills <br />(7laase print name and titla) <br />Sidn.aturA______ <br />(~?rsJn Served) <br /> <br />w["lE0 haw/~a.yail0^~ 7IVISIJrv <br />3 Y---------- ~ ---- ------~-- <br />(autnorized repre ntative) <br />Michael S. Savage, Reclamation S ecialist <br />(`lace and title - please print) <br />I4o~3i2TdVT: PLEASE READ THE REVERSE SIDE OF iNIS oaGE. <br />10/79 C.R.S. 1973. 34-33-123 <br />