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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />7 373 Sherman St., Room 215 AUG 0 5 2005 C O L O RAD O <br />Denver, Colorado 80203 DIVISION O F <br />Phone: (303) 8663567 MINERAL S <br />FAX: (303) 832-8106 6irlision ~f Minerals and Geology <br />GEOLOGY <br />AUTHORIZATION FOR PAYMENT RE<LAN ATION•NININO <br />EAf ETY•SCIEN CF <br />BY CREDIT CARD Bill Owens <br />Governor <br />(MASTER CARD/VISA ONLY) Execeultlive Digeclor <br />Ronald W. Cattany <br />Division Direttor <br />Natural Resource Trustee <br />Please indicate the amount you aze authorizing. <br />Description ~ Amount: $ 5 <br />yy,,qq ~~ ~~ <br />Description ~iU"`ei~'r° ~ Amount: $ <br />Description Amount: $ <br />Description Amount: $ <br />/ Total Amount to be Chazged $ c ~ <br />Master Cazd / Visa <br /> Expiration ~~ <br />~'~"~- <br />The issuer of the cazd identified on this item is authorized to pay the amount shown as TOTAL upon ~~~~" <br />proper presentation. I promise to pay such TOTAL (together with any other chazges due thereon) subject ~l-~ <br />to and in accordance with the agreement governing the use of such cazd. <br />Ofrice of <br />Mined Land Reclamation <br />Print name as it appeazs on Cazd: ~ t ~~~ Q J . (~U U ~` l n -2 y _/~ <br />~~ 5 <br />%~ - ~' ~1~ <br />Signa~ `-'~ l v <br />Office of <br />Active and Inactive Mines <br />Colorado <br />f:unlnni~al G~..,e., <br />