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<br /> MINED V ~ RECLAMATION DIVISION NO 06875 <br /> 13,. Sherman, Room 423 <br />Denver, Colorado 80203 DATE ~ 19 -`/~ <br />(.3{03) 8663567 _ <br />RECEIVED FROM `~ ~~~~-t~1 ~~~~~ v1 <br /> C <br />THE 5UM OF ~~'~'~~~ ~~~ ~ ~ ~ ~~OOLLARS $ ~/D • ~T~~ <br />FOR ~C-~~ V~ l vc/ ~~ ! ~ I / 3~ r9 oMaCK <br /> <br /> AMOUNT OF ACCOUNT...... $ <br />~in~e oul <br /> AMOUNT PAID ................ $ , J ~~ <br />,. ~ <br /> BALANCE DUE ..... ......... $ BY ' <br /> <br />