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<br /> <br />Dat? of 5?rvice__T~arch 30___, Iq 82 <br />person $?rv .d Mr. Dave Gossett <br />(Please print name antl title) <br />S(tl(I3LJf?_________________________ <br />(P?rSJn 5?r'+?tl( <br /> <br />!!IME7 lswp 4Ert.~.Mai[0`~ 7IVISIOv <br />~Y--- /G~.J~ ------ - <br />(d~:r'DriZetl rgpr enCdtive)- <br />Michael S. Sa va qe, Reclamation Specialist <br />(`:d •re dntl c~tle - Gleas? Drint) <br />I.4~~ii in'vi: PLEASE ~E~O THE REVERSE SIDE OF THIS oeGc. <br />tC/79 C.a.S. 19 T3, 34-33-123 <br /> <br />