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<br />Date of Service_~y~m~P,r ___• 19Zg <br />Person Served <br />Tanac A-J,aTSo11=-~Sl rlant- __________ <br />(Please print name and title) <br />Siynature------------------------- <br />(Person served) <br /> <br />MINED LAND RECLAMaTION DIVISION <br />gy--------------------------- <br />(authorized representative) <br />Richard_M_ills/ Reclam_a_ti_o_n-~ecialist___ <br />(Name and title - please print) <br />IMPORTarIT: PLEaSE REaD THE REVERSE SIDE OF TH[S PaGE. <br />1/79 C.R.S. 1973, 34-33-123 <br /> <br />