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iii iiiiiiiiuiiiiii <br />DIVISION OF MINERALS AND GEOLOGY N~ 2 6 5 9 3 <br />DATE ~ 19 ~~ <br />RECEIVED <br />FROM- <br /> <br />~~~ <br />~ <br />~ <br />/ ~~ ~~ <br />/L ~C S <br />_/ <br />' <br />/ <br />FOR /UDY ( <br />~ ~_~Y ~/ <br />/ <br />`(~~`1 ''1C/ <br />/ <br />L .~~~~Q.~L/ OCASH <br />^ MOCK <br />AMOUNT OF ACCOUNT...........$ <br />AMOUNT PAIO .. ...... ..... ..$ <br />~ou~ <br />BALANCE DUE . .................$ <br />