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r. <br />MINED LAND RECLAMATION DIVISION <br />CERTIFICATE OF SERVICE <br />PERMIT NO.• <br />C.O. NO.: <br />N.O.V. NO.: - - " <br />I hereby certify that I served a copy of the foregoing NOTICE OF <br />PROPOSED AMOUNT OF CIVIL PENALTY on the operator therein described <br />by depositing a true copy thereof first class postage prepaid in <br />the United States mails at Denver, Colorado, addressed to the <br />operator at the address above, on , ~`,,,;,,,s i^ i'?. ~ "' <br />Certified Mail No.: <br />Return Receipt Requested <br />~ _ ~ <br />Signature of Person Served (Signature) <br />LGi)'V r /~nc~t ~': i77S'F5S'vlr:~i7~ r-. r(Pr' <br />Print Name and Title Print'Name and Title <br />REQUEST FOR CONFERENCE <br />The operator above described hereby requests an assessment <br />conference as permitted by C.R.S. 34-33-123(8). <br />Operator <br />By <br />(Signature) <br />Date 19 <br />c:\wp51\proppen <br />/ V' I <br />Credit - Rapid Compilance <br /> <br />.1' . r r ~ <br />_~..- , ~.,. .~'- ;)cam c,~C`it--' Assessment Officer <br />Slgnat f~ y ~7 <br />L.%r'Pli /7 ~~;?L~/ fY) Date i/ Y-C[r1 !i ~ y ~'-Z. <br />Name Printed <br />4672E <br />