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<br /> MINED LAND RECLAMATION DIVISION N~ 0 0 5 6 6 4
<br />1313 Sherman Street Room 42~
<br /> Denver, CO 80203 DATE y- ~ 10 ~2
<br />(303) 866-356
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<br />RECEIVED FROM ~-GY-C~1I YlAX~I /r
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<br /> `~~`~~,rryy//~~+77
<br />THE SUM OF~ ~1ArY 1 yDE]CLARS $ /x '~-~~G
<br /> FOR •I,VI, W~~ /~I~ x(/~ Y'y ~OIIIV ^MOCK
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<br /> AMOUNT OF ACCOUNT...... $ ~j~
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<br />AMOUNT PAID ................ $
<br /> BALANCE DUE ............... $ BY
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