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DIVISION OF MINERALS AND G. BOGY N~ ,2/~6 6 9 6 <br />DATE ____i.~ 19 <br /> RECEIVED / ~ Z $ <br />F <br />R <br />O <br />M <br /> , <br />/ p ~-_---- <br />~ <br />J <br /> ~~ 0 QECK <br />FOR []~~.. <br />~`_.LL- <br />_~ / <br />L <br />V <br />~ <br />~ <br />/! <br />~ <br />~ <br />AMOUNT OF ACCOUNT , .........$ 1 +~"' ~ _ ~ ~(`~'° ~f 1,~ ~ 1 <br />AMOUNT PAID ... ..... . .........$ v uIl ~~u I <br />t <br />BALANCE DUE ............. ....$ BV <br /> <br />