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2 <br />` M' <br />Date of Service~u „~1- 6 _, 1~_SC3 <br />~---- - <br />Person Servea_____________________ <br />-=--------° ---------------------- <br />(Please print name ano title) <br />Signature------------------------- <br />(?erson sarved) <br />• <br />MINE~i ylc'yD RECLA.MaITICY DIVISID`I <br />(duthOriZe~I r?presentative) <br />Carol Pahlke - Reclamation Specialist <br />------------------------- --------- <br />(yame anJ title - Tease print) <br />I~1PDRTA?JT: °LEaSE READ TAE REVERSE SIDE OF Tr+[S PaGE. <br />17/7 C.R.S. 1773 34-33-123 <br />S~r~r~ ~- Ly c< <br /> <br /> <br />