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STATE OF COLOlZADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />1313 Sherman St., Room 215 AU6 0 5 2005 C O L O RA D O <br />Denver, Colorado 80203 D 1 v 1 5 1 o N o f <br />Phone: (303) 8663567 <br />FAX <br />0 <br />~f Minerals and Geology <br />i <br />i MINERAL S <br />: (3 <br />3) 832-8106 on <br />s <br />liiv GEOLOGY <br /> AU'T'HORIZATION FOR PAYMENT RE<LAN ATIO N•MINING <br />EAFETY•ECIENOE <br /> BY CREDIT CARD <br /> Bill Owens <br /> Governor <br /> (MASTER CARD/VISA ONLY) E>i~~°i a Digectar <br /> Ronald W. Catlany <br /> Division Director <br /> Natural Resource Trustee <br />Please indicate the amount you aze authorizing. <br /> S ~' <br />~ <br />Description Amount: $ <br />~~ ~ <br />"~ <br />Description Amount: $ <br />Description Amount: $ <br />Description <br />Amount: <br />Total Amount to be Chazged $ ~ ~ ~~ <br />Master Cazd / Visa <br /> Expiration ~.~ <br />/" <br />,, ,,f <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 Jt1- <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 appeazs on Cazd: ~ ~ / ~~ ~ J ~ l ~C~ l.( ~~ l n $ y /1~ <br />~ 5 <br />%.,:,~ - 9 g plc <br />Signature `~ 1 <br />Office of <br />Active and Inactive Mines <br />Colorado <br />('n..l....:~~1 c.....e.. <br />