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<br /> MINED l D RECLAMATION DIVISION N! ~ ~ 7 9 ~ 5 <br /> 1313 Sherman, Room 473 <br /> Denier, Colorado 80703 j' j~ <br />DATE ~ /~'19 U ~C' <br /> ( <br />3 <br />7 <br />0 <br />3) 866-356 <br /> ( <br />~ <br />- <br />~ <br />~7 <br />{ <br />RECEIVED FROM L• ~~L L N 7'~ L C - ~~ y r OL~!'1 <br /> ~/(~/ / <br />~ <br />~~ <br />~ <br /> THE SUM OF <br />DOLLARS $ ~_' <br />` <br /> (~ cAS-i <br /> FOR E-krLal~~t ~;7~--~sN P, ra~.3 MOCK <br /> <br /> AMOUNT OF ACCOUNT..... , $ (_r <br />~ <br />'~ <br />l <br />O ' <br /> 11 UII <br />~l {A <br />ll <br />~,.J <br />AMOUNT PAID ................ $ <br /> BALANCE DUE ............... $ BY ~ - ' <br /> <br />