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<br /> DIVISION OF MINERALS AND GEOLOGY N~ 7 4 3 6 <br /> ~ <br />e~L~ <br /> 19 <br />GATE ----1 <br /> <br />M / $ <br />RECEIVE <br />~ <br /> ~Y~ ~-! ' <br />FROM A-Y ~ 4' <br /> ~- "~ <br /> YG ` <br /> -~~-/~~ <br />O CASH <br />7 ^ CHECK <br /> ~ M.O. <br />FOR n°~ n <br /> <br /> 2/^r7 <br />AMOUNT OF ACCOUNT...........~~-TJ / <br />Qhi ~OUI <br /> AMOUNT PAIO ...................$ <br /> BALANCE DUE .............. ... $ t^ <br /> <br />