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jPS Form 3500, June 1985 <br />d <br />o ~ <br />O O D <br />um <br />n~ O D <br />Fm D <br />m N <br />~ f7 <br />~ O <br />° <br />d T <br />CO (/~ <br />2m N <br />t° <br />3 <br />3 <br />~ > <br />~ d 3 <br />°D i~ <br />o <br />3D ^ <br />m o <br />m <br />o = <br />a ,n <br />'~ i <br />aa m <br />~+ ~ <br />m <br />U1~ 6 <br /> ° <br />u n,y y ry <br />n n <br />° q <br />m T <br />~ <br />o <br />O ~ no a <br />O = ' n <br />y <br />R mH <br />T N <br />,p O .c <br />~ N ~p <br /> os ~ " ~ ,c <br /> <br />~3 <br /> <br />~ <br />g _ <br />° <br /> <br />~ A a <br />o > <br />~b <br />O <br /> <br />~ <br />'~ I c <br />~ <br />~ -~ r <br />~ <br />_, <br />~ N c <br /> Q <br /> a~ <br /> r <br />p a <br />5l fm1 U <br />m <br />~ J <br />o z 1 0- <br />y a i p v <br />m =m ~ <br />anon F <br />mm <br />`° o> a .~ <br />gm~ <br />or <br />,0 ><m ~ <br />~ mo <br />s `~ <br />., r <br />~~ <br /> MINED L' ~ RECLAMATION DIVISION N ~ 0115 7 5 <br /> I~._ Sherman, Room 215 <br /> ~ <br />Denver, Colorado 80]03 DATE ~' ~\ ~gS U <br /> (303) 866-3561 <br /> RECEIVED f~ <br />$ <br /> n - --F n <br />FROM R ~l,a <br />~A~~/~L ur'. OQ <br />~y Ci l~-m~-1+,y <br /> a <br />, <br />1 1 00~ <br /> ~ r--r, ~ ., v*i n ~ g <br />~L~ r - y' 1/Pn-BOLLARS <br /> , <br /> ^ CASH <br /> ~ ~ CHECK <br />FOR ra ......... J • s ~~j <br />'1- C1 n ~, \ <br />M <br />O <br /> e <br />. <br />. <br />- <br /> AMOUNT OF ACCOUNT. .... .....$ ~ <br />IA /~ <br />~ <br />I <br /> ~OU <br />IIQh <br />AMOUNT PAID .... .............. $ <br /> BALANCE DUE . ........... .. .....$ B ~~" <br />