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<br /> MINED LAND RECLAMATION DI' 7N N O ~ ~ T 7 21 <br /> 1313 Sherman, Room 423 - <br />Demrer, Colorado 802()3 PATE ~9 <br />(30 566-3567 mo~tt,~ ~~ ~~ 1/}--~J //~J~±~/~/(J7~'q <br />RECEIVED FROM U/'C • ~"~/~(X 1. [t~~C <br />~ <br /> ~~r \ <br />/, <br />THE SUM OF ` DOLLARS $ V v <br />~E K <br />FDR ~ Y ~ QMf] <br /> AMOUNT OF ACCOUNT...... $ <br />Hank oul <br /> AMOUNT PAID ................ $ <br /> BALANCE DUE ............... $ BY <br /> <br />