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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resources <br />1373 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 8663567 <br />FAX: (303) 832$706 <br />RECEIVED <br />AUG 0 5 2005 <br />Division ~f Minerals and Geology <br />AUTHORIZATION FOR PAYMENT <br />BY CREDIT CARD <br />(MASTER CARD/VISA ONLY) <br />COLORADO <br />DIVISION OF <br />MIN SRALS <br />GEOLOGY <br />0.EC LAM ATION•NINING <br />SAFETY•SCIEN CE <br />giu a,eern <br />Governor <br />Russell George <br />Executive Director <br />Ronald W. Cottony <br />Division Director <br />Natural Resource Trustee <br />Please indicate tv~h~;e,_amo~uQnt you are authorizing. <br />Description ~/"""""°"'' ~ Amount: $ S <br />Description ~~L~"`ei~xd ~ Amount: $ <br />Description Amount: $ <br />Description <br />Amount: <br />/ Total Amount to be Chazged $ c d v <br />Master Cazd / Visa <br />_~' ~ ~ ~ ~~ C~ ~~ 8 0 ~¢ U ~ `l ~ S Expiration Cri~/ fis <br />,,,,t <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 f11- <br />to and in accordance with the agreement governing the use of such cazd. <br />Print name as it appeazs on Cazd: 1 /+ f ~~~~~ ~ (~U U ~` ~n ~ ~ _,~ <br />l " ,~7 <br />~y <br />Signat-~ ~ ~ b ~ ~~ <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines r:o~l,.,.l~,l c,..,,e•, <br />