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DIVISION OF MINERALS AND GEOLOGY N2 -22264`'7{Jl6 <br /> DATE �pr -C`v 19/ <br /> RECEIVEv $ J'y <br /> FROM <br /> DOLLARS <br /> p7 ❑ CASH <br /> FOR&OI/ !.3 I3 <br /> AMOUNT OF ACCOUNT.. .. .....$ <br /> QVl�2 OUI <br /> AMOUNT PAID................ ..$_ <br /> BALANCE DUE....... ...........5 BY <br />