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<br /> MINED l qND RECLAMATION DIVISION N D 1 7 6 <br />1313 . Sherman Street Room 423 <br /> Denver. CO 80203 <br />(303) 866-3567 DATE 2 3 ~9~_ <br /> RECEIVED FROM UG5=~C0 _ <br /> nn 1 1 ~~ 00 <br />.THE SUM OF ~C\rv~.cL~...+~~cCnr A/ .I ~N ~'..t DOLLARS $ 3`50 .~~ <br />^ cns.+ <br />FOR '~./+-~ ~4 -1-I Z 2 Z. 3QSSZ ~ ocK <br /> AMOUNT OF ACCOUNT...... $ <br />and ou( <br /> AMOUNT PAID ................ $ <br /> BALANCE DUE ............... $ BY <br /> <br />