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<br /> <br /> DIVISION OF MINERALS AND GEOLOGY N <br />I ~ f~ 3 9 6 <br />~ <br />r = <br /> ---J <br />-19 <br />DATE <br />oC~. <br /> RECEIVED 4 ~ ///~ $ <br /> <br /> <br /> _/~YCrI~ <br />~~ ~ ~O <br />! /~ LY <br />O <br />7 <br /> X7 <br />! <br />G <br />~/ <br />^ M.O. <br /> AMOUNT OF ACCOUNT...........$ ~ D D r P'~^ /~I'^^'~^ /~U~ 11II <br />LI I <br />` <br />l <br /> IIQII IL <br />N <br />AMOUNT PAID ....... ... .. ... $ <br />Ou <br /> BALANCE DUE ...................$ V <br /> <br />