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<br /> DIVISION OF MINERALS AND GEOLOGY 'v <br />3 <br />40 <br /> 4 <br />---yG~;[000~- <br />DATE 19 / <br /> / / <br />RECEIVEDu ~/: ~/~~., /,~~ 1r~ $ ~s' ~ <br />/( <br />~ <br />FRO <br />M <br />I/L~~ ~ £, <br /> ) /~ //~ <br />.,/ <br />~ <br />~ <br />~ <br />~"G/E~TG/ fl~ ~~~T"'TitS7~RS <br />//.a-~(% f/L~~i~f"U" <br /> ^ <br />~7 <br />i''lI ~~/ /~~ ^ CHECK <br />^ M.O. <br />FORG/11~ ~ <br /> ~ <br />/'1 ~ 7 <br />AMOUNT OF ACCOUNT ..........5~~ ~ /~` <br />a ~ou ~ <br /> AMOUNT PAID ... .......... ....5 <br /> BALANCE OUE . .................~ Y <br /> <br />