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iii iiiiiiiiiiiu iii ~ <br /> <br />MINED LAND RECLAMATION DIVIvJ N p ~ 12 3 <br />1313 Sherman Street Room 423 <br />Denver, CO 80203 PATE Z ~s ~.~ <br />- (303) 866-3567 ~I-~'- <br />RECEIVED FROM Z ~^-'~Q-Cis Y~. J .~F'~1 ~~'M . <br />THE SUM OF ~h,.-_...A.~s cO 1..IL..~.a..n DOLLARS $ ~SS hC] <br />r] C45H <br />FOR Qirn~~c~ $1 ' ZC~`I ~ 1 Tl5 1 ~c aCK <br />M <br /> <br />AMOUNT OF ACCOUNT...... $ <br />an(e out <br />AMOUNT PAID ................ $ <br />BALANCE DUE ............... $ BY ~ <br /> <br />