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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />13135herman St., ROOm 2i5 AUG 0 5 2005 COLORADO <br />Denver, Colorado 00203 DIVISION O F <br />Phone: (303) 8663567 <br />f Minerals and Geology MINERAL S <br />fAX: (303) 832$106 6iuision ~ GEOLOGY <br /> <br />AUTHORIZATION FOR PAYMENT REGLANATION•NINING <br />SAFETY•ECIENCE <br /> BY CREDIT CARD <br /> Bill Owens <br /> Governor <br /> (MASTER CARD/VISA ONLY) E=~wli a DiBector <br /> Ronald W. Cattany <br /> Division Din!ctor <br /> Natural Resource Trustee <br />Please indicate the amount you aze authorizing. <br /> ~ <br />S <br />Description Amount: $ <br />qq ~~ <br />~~w ~~ ~- <br />e <br />~ <br />Description <br />"ei~°" d <br />Amount: $ <br />Description <br />Description <br />Amount: <br />Amount: $ <br />Total Amount to be Chazged $ <br />1~~~ <br />Master Cazd / Visa <br />S ~ ~ ~ ~~ U U 8 ~ ~ U ~ ~ s Expiration ~~l ~S <br />Print name as it appears on Card: ~ r ~/~ {~ J . l ~U U ~^ fn -2 ~ ^ ~y~ _/~ <br />I ~" ~ <br />Signature ~ ,/~~;~~ <br />The issuer of the card identified on this item is authorized to pay the amount shown as TOTAL upon <br />proper presentation. I gromise to pay such TOTAL (together with any other charges due thereon) subject }11- <br />to and in accordance with the agreement governing the use of such cazd. <br />Once of <br />Mined Land Reclamation <br />Office of <br />Active and Inactive Mines <br />Colorado <br />