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<br /> DIV N OF MINERALS AND GEOLOGY J O 2 5 7 2 T <br />_ - <br /> ~jz <br />DATE ~ z' 2 ~ 19~ <br /> RECENED $ <br /> L`-'-`1~~J <br />FROM <br /> <br /> <br /> DOLLARS <br /> <br /> ~ ^ CASH <br />~-CHECK <br />FOR~'h - c~ ^ M.O. <br /> <br /> AMOUNT ACCOUNT...... ....$ <br /> <br />QNI2~ OU ~ <br />AMOUNT PAID . ....... ...... .$ <br /> BALANCE DUE ..................$ BY <br /> <br />