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<br />Dd[2 of Service__AUgust_28,_~ 19 81 <br />~er5on 5?rv~d Mr. Steve Self <br />--------------------- <br />-------------------- ------------- <br />(?leave print name and title) <br />Sianac.~re______ <br />(Pors~n served) <br /> <br />M["lED L~uJ RECLS.M~ifO"~ OIVISIJN <br />a Y----------------------- <br />(autnorized representative) <br />Robert Liddle, Reclamation Specialist <br />----------- --------------------- <br />(^laTe and title - please print) <br />I,M?Oitia.vT: RtEaSE REaD THE REVERSE SIDE OF THIS aaGE. <br />10/79 %.R.S. 1973, 34-33-123 <br /> <br />