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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />1313 Sherman S[., Room 215 AUG 0 5 2005 C O L D RA D O <br />Denver, Colorado 80203 D I V 15 t O N O F <br />Phone: (303) 866-3567 <br />FAX <br />(303) 832 <br />8106 <br />ision ~f Minerals and Geology <br />Di MINERAL S <br />: <br />- v GEOLOGY <br /> AUTHORIZATION FOR PAYMENT 0.ECLAN ATIO N•NI NING <br />SAIETY•ECIf NCE <br /> BY CREDIT CARD <br /> Bill Owens <br /> Governor <br /> (MASTER CARD/VTSA ONLY) Russell George <br />Executive Direcor <br /> Ronald W. Cadany <br /> Division Director <br /> Natural Resource Trustee <br />Please indicate the amount you aze authorizing. <br /> S <br />~ <br />Description Amount: $ <br />~ c <br />~ <br />"~ <br />P <br />Description <br />' Amount: $ <br />° <br />Description Amount: $ <br />Description Amount: $ <br />/ Total Amount to be Chazged $ C ~ V- <br />Master Cazd / Visa <br /> Expiration ~f2/ ~~ <br />~~ <br />,, ,,v <br />The issuer of the cazd identified on this item is authorized to pay the amount shown as TOTAL upon / U <br />proper presentation. I promise to pay such TOTAL (together with any other chazges due thereon) subject ~- <br />to and in accordance with the agreement governing the use of such cazd. <br />Colorado <br />Print name as it appeazs on Cazd: 1 /~ f l ~i {~ J - (~ U f ~n ~ y ,l~ <br />(V / <br />Signature `-'~ l , <br />Office of <br />Mined Land Reclamation <br />Office of <br />Active and Inactive Mines <br />