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DIVISIG~. OF MINERALS AND GEOLOGY I~_' 22598 <br />9 <br /> c <br />DATE ~;~ 19 / 3 <br /> RECENED ~ $® <br /> FRDM <br /> Cst~ <br /> DoLL.ARs <br /> <br /> ~ <br /> /y~ '/ 8-CHECK <br />~ <br />~D~ ~`i'3 <br />~ <br />~~ <br /> o <br />,E <br />FORR21Ta iP ~ /~I ~ <br />O M.O. <br /> /// <br />/// <br /> A <br />AMOUNT OF UUU <br />CCOUNT...... ... $ 1' <br />~~~ QUI <br /> AMOUNT PAID. <br /> BALANCE DUE ............. ......$ BY <br /> <br />