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III lllllllllllll 111 <br />999 <br /> <br /> DIYISlO"' OF MINERALS AND GEOLOGY ' ~ ~ 2 3 9 9 <br />5 <br /> 2 <br />q <br />DATE ~ 19 / `'~ <br /> RECEIVED f - $ / ~ <br /> J <br />FROM <br /> ~ DOLLARS <br /> <br /> /~~,~ I .y/ p <br />~ <br />M <br />K <br /> a' ~L.(O~ p <br />p, <br />FOR` LN/V/i N ~ /' / - Ot <br /> <br /> AMOUNT OF A UNT...........$ <br />K~ ou. <br /> AMOUNT PA10 .. ................$ <br /> BALANCE DUE ........ ..........$ BY <br /> <br />