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<br /> DIVISI OF MINERALS AND.GEOLOGY _~ 23735 <br />DATE `~ ~ 19~ <br />RECEIVED ^ _ n Q „ _ _~_ /'~ $ ~ ~S <br />Kr~+q ~C.~ <br />OM .~lA3G/~A.JL. <br />IW <br />G~ <br />F <br /> R <br />/ <br />~ <br />-(] <br />C ~ <br />IJ <br />~ <br />~~ <br /> GJ!_ C.v~ <br />at ~l <br />_]LJ aJQ.vIL <br />~ <br />DDLLAR9 <br /> ~ <br /> ^ CASH <br />((''~~ ~ CHECK <br />T.JLII._ N/1 - Z = ~ 3 Y .3d~ ^ M.O. <br />FOR ~K~ <br /> ~ <br /> AMOUNT OF ACCOUNT..... .....$ <br />l <br /> AMOUNT PAID ............ .......$ ~~ ou <br />/ <br />/ <br />/ <br /> ~ <br />~ <br />BALANCE DUE . ..................$ BY ~~/__000~ <br /> <br />