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<br /> DIVIS,~ OF MINERALS AND GEOLOGY ~ 0 '~ 5 T ~ L <br />r <br /> <br />DATE ~ 19 ~~ <br />/~ : ,: ; <br /> <br /> /~/ <br />~` <br /> _ <br />^ CASH <br />^ HECK <br />FOR~Ll1 - ^ M <br />0. <br /> . <br /> AMOUNT 0 ACCOUNT.... ......$ -IQ/I~ /~ ~ u' <br />(/l <br />e//Q/~ <br />AMOUNT PAID ... .... ......... $ I, <br />~~p'( <br /> y <br />~ <br />l <br />BALANCE DUE. ...........'. .. .$ B`/ <br /> <br />