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<br /> DIVISION OF MINERALS AND GEOLOGY N~ 24147 <br /> DATE ~'19~ <br /> RECEIVE <br />$ c <br /> _ <br />FROM d <br /> D~ DOLCAR9 <br /> ~1 -/ /~ Q /' ^ CASH <br /> <br /> <br /> AMOUNT OF OUM...........$ ~~' ^M^ <br /> AMOUNT PAID ........... ........$ <br />~C\~~/n <br />{ <br /> / <br />BALANCE DUE . .................$ BY 1/ <br /> <br />