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DIVISION OF MINERALS AND GEOLOGY NO 06 <br />~~ .~-., DATE ~ 19 <br />RECEIVED ~ / $ <br />F ~ ~'/ ~ ~. <br />~ ~~~ DOLLARS <br /> <br />y/, ~~L <br />FOR ~/~/~J //ELI ~,~1"~-~l ~i'f ^MOCK <br />AMOUNT OF ACCOUNT.. ... ... $ ~ /O~ r' f~ ~11,~'~^ ~1 ~ <br />.. N <br />VlI2 ~l <br />I <br />Ji DU <br />Q <br />AMOUNT PAID .......... ... ....$ <br />BALANCE DUE . ..... ... ........$ <br /> <br />