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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 2005 C O L D RA D O <br />Denver, Colorado 80203 D 1 V i S t o N O e <br />Phone: (303) 866-3567 <br />i Minerals and Geology MINERAL S <br />FAX: (303) 832-8106 Division ~ GEOLOGY <br /> AUTHORIZATION FOR PAYMENT REC LAM ATIO N•NINING <br />SAf ETY•SCIENCF <br /> BY CREDIT CARD <br /> Bill Owens <br /> Governor <br /> (MASTER CARD/VISA ONLY) E,°~u°~ a Digector <br /> Ronald W. Cattany <br /> Division Director <br /> Ndturd) Re5pu2e TNStee <br />Please indicate the amount you are authorizing. <br /> ~-. <br />~ <br />S <br />Description Amount: $ <br />~~w <br />e ~ <br />Description <br />"P'u" <br />g Amount: $ <br />Description Amount: $ <br />Description Amount: $ <br />/ Total Amount to be Chazged $ c U V <br />Master Cazd / Visa <br />~~ !, Expiration ~ <br />~~- <br />,,,,v <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 11~- <br />to and in accordance with the agreement governing the use of such cazd. <br />Print name as it appeazs on Cazd: ~ 1 / ~~~{~ J ~ (,r~ U ~~ ~n -~ ~ ill <br />~~ <br />Signature T `~ J <br />Office of <br />Mined Land Reclamation <br />Office of <br />Active and Inactive Mines <br />Colorado <br />