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I~ <br />DIVISION OF MINERALS AND GEOLOGY <br />•,~ <br />N°_ 2636C~2~ <br />DATE ~ Z - 7 19 t ~ ~ <br />$ ~~. <br />^ CASH <br />$6k1ECK <br />~ M.O. <br />AMOUNT OF ACCOUNT.... $ <br />AMOUNT PAID .... .$ <br />flALANCE CUE ... . $ <br />~_____ <br />r` <br />~ SEND <br />q • Complete ttems t tvd/or 11or adtlitional sernces. <br />p • Compllt¢ items 3. and 4e 8 b. <br />• • Pnnt your name end address on the reverse of this farm eo that we c <br />return this Celtl LO You. ' <br />V • Arach this form tp the front o/ IhE mailpiece, or on the bath; f ape <br />tloes not permit. <br />t • Write "Return Receipr Requested" on the mailpiece belpw the erticb r <br />• -The Re[urn Receipt will show to whom the article was deNVared and r <br />C M'iveretl. <br />v 3. Article Addressed to: r <br />0 <br />~~~.+ C.aA4'1' <br />~ I ~'^~~'~" 4b. <br />~v~K.bAN ~J1~NR> • torzAJa Cp ^ Ra <br />w Syo U ~~ J `_ O ExPn <br />K <br />~ RKV~a4 ~d $DOO ~, 7. Dateo <br />O <br />Q <br />Z e dd eel 8. AddresseE <br />K <br />7 / and Yee is . <br />f <br />¢ 6. Signatu e I gentl +~ <br />PS Form 71, December 1987 w.aoPat~an~ DOMES <br />~1Q41~ ~OU ~ I <br />BY <br />