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iiiiiiiiiiiuiuiii <br /> MINED LAND ,;LAMATION DIVISION N ° <br />--~ 0 5 6 7 2 <br /> _ <br />1313 Sherman Street Room 423 <br /> Denver, CO 80203 ` <br />A°~ <br />!~ <br /> ~sQ <br />(303) 866-3567 DATE <br /> (/~'1 <br />~ ~ Il ~~ r ~ p^~~ w ' <br /> RECEIVED FROM <br /> J~/~ <br />q O~ ~Z3~~OLLARS $ ~O <br />(/~ <br />/ <br /> • <br />- <br />THE SUM OF <br /> FOR / ~ n'l/1'L //1 C1I 'V~ ~ ~Q 7~ ~0 ~„~oCK <br /> <br /> AMOUNT OF ACCOUNT.. ... $ <br />~ QUI <br />l <br /> ~J I <br />Ull <br />AMOUNT PAID .... ........... $ <br /> BALANCE DUE ............... $ BY - <br /> <br />