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<br /> MINE' 4ND RECLAMATION DIVlSlON ~ Q Q ~ a 14 <br />f313 Sherman ' <br /> Denver, Colorado 80]03 DnrE~~9 ~~ •a <br />(303) 866-3567 <br />FFOM ~~ ll„ <br />C~ <br /> DOLLARS <br />~~- `a <br /> <br /> ^ CA$H <br />FOR CC i\ 1 -~_C ~~/' :7/. ~f~ c~.1~;( p pK <br /> <br /> AMOUNT OF ACCOUNT .. ... .. $ <br />OUI <br />Q <br /> J"`~ <br />AMOUNT PAID .......... ........$ ~ <br />/ <br />,. <br /> C <br />l <br />J ~ i <br />BALANCE DUE ..... ... .. ......$ BY ti[ <br /> <br />