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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />1313 Sherman St, Room 215 AUG 0 5 2~J C O L O RAD O <br />Denver, Colorado 80203 DIVISION D F <br />Phone: (303) 866-3567 MIN <br />RAL S <br />FAX: (303) 832-8106 Division ~f Minerals and Geology E <br /> GEOLOGY <br /> AUTHORIZATION FOR PAYMENT M1EC LAM ATION•N INING <br />SArETY•ECIENCE <br /> BY CREDIT CARD <br /> 6alOwens <br /> Governor <br /> (MASTER CARD/VISA ONLY) Russell George <br />Exec Wive DlreCtOr <br /> Ronald W. Cattany <br /> Division Direttor <br /> Natural Resource Trustee <br />Please indicate the amount you aze authorizing. <br />Description Amount: $ <br />5~ <br />q ~ <br />~~u" ~ <br />x <br />~ "~ <br />Description <br />'Q "~°' <br />d <br />Amount: $ <br />Description Amount: $ <br />Description Amount: $ <br /> <br /> Total Amount to be Chazged $ C <br />Master Cazd / Visa <br />S ~ ~ ~ ~~ U CJ 8 ~ ~ 0 ,~ `l ~ s Expiration ~~l ~is <br />/" <br />The issuer of the cazd identified on this item is authorized [o pay the amount shown as TOTAL upon ~` <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 />Office of <br />Mined Land Reclamation <br />Print name as it appears on Cazd: 1 /! ~ l ~i {~ J - l ~U U ~' fn -~ y _l~ <br />~~ / <br />- `~ ~, ~ / 5 <br />Signature <br />Office of <br />Active and Inactive Mines <br />Colorado <br />