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<br /> DIVISION OF MINERALS AND GEOLOGY N~ 743 <br />~ DATE ~ /~19 <br /> //J <br />RECEIVEDLtiGL~ Gv ~ ~.Y~/ /f~ i ~/~I~ $ ~L~ <br />FROM <br /> <br /> <br /> <br /> FOR ~~~ /// - /F"~~U ^ CHECK <br />^ M.O. <br /> <br /> ?) <br />AMOUNT OF ACCOUNT......... .$ ~~ ~/~' <br />QN ~OU~ <br /> AMOUNT PAID . .......... .....$ <br />t <br /> BALANCE DUE ..... .............$ B <br /> <br />