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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br /> <br />1313 Sherman St., Room 215 EEf1~ <br />QUG Q 5 2005 <br />V <br />C O L O 1tA D O <br />Denver, Colorado 80203 D 1 V 1 5 1 O N O F <br />Phone: (303) 8663567 <br />f Minerals and Geology MINERAL $ <br />FAX: (303) 832-8106 Division ~ GEOLOGY <br /> AUTHORIZATION FOR PAYMENT aECIANATION•M INING <br />EAf ET Y•Sq ENCE <br /> BY CREDIT CARD <br /> Bill Owens <br /> Govelrror <br /> (MASTER CARD/VISA ONLY) E:~c~°i a Digeaor <br /> Ronald W. Cattany <br /> Division DiretTOr <br /> Natural Resource Trustee <br />Please indicate the amount you are authorizing. <br /> ~ <br />5 <br />Description Amount: $ <br />~ <br />~ c <br />~ <br />"~ <br />Description <br />`e' <br />° Amount: $ <br />Description Amount: $ <br />Description <br />Amount: $ <br />/ Total Amount to be Chazged $ c ~ V~ <br />Master Cazd / Visa <br />s 1~ ~ ~ ~~ ~ CJ 8 0 ~ (j ~ `~ ~ S Expiration Q~l ~S <br />Print name as it appeazs on Cazd: T n r ~~r {~ J ~ ~~ ~ ~- f "n 2 <br />~~ / <br />Signature ~ 1~~ <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 Jll- <br />to and in accordance with the agreement governing the use of such Cazd. <br />Office of <br />Mined Land Reclamation <br />Office of <br />An'rve and InaCtlVe Mines <br />~~~ <br />Colorado <br />r•.e,.t....t~.t c....,e.. <br />