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<br /> DIVISION OF MINERALS AND GEOLOGY I'"' 24703 <br /> DATE ~ ~ 19~ <br /> /~ <br />RECEIVED ! "_ ~-Y- $ ~c, .nl <br />FROM ~-tT~ L / UJ <br /> ~~ ODLLARS <br /> ^ CASH <br />B 6HECK <br />FOR _ ~ I ~~ ^ M.O. <br /> <br /> AMOUNT OF ACCOUNT...........$ P ~ '1 <br />I <br /> AMOUNT PAID ...... .. ... ... .$ U <br />/ <br /> BIUANCE DUE ...... ............$ BY <br /> <br />