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<br /> MINE' 'AND RECLAMATION DIVISION V ~ 215 5 6 <br /> _-1313 Sherman, Rm. ZIS. ~, J <br />Denver, Colorad'o' 80203 <br />~ Z <br /> DATE ~_~ t s <br />(303) 866-3567 <br /> ,f~~ <br />~ <br />$ ~ <br />F <br />VE <br /> J() J~0 d~ <br />75 <br />ROM <br />RCL~ <br /> ~ ~ Y ~ <br />/' ~ S;I <br /> i <br />ooLLAHs <br /> <br /> ^ CASH <br />~.GHECK <br />FORCi~ ~ ~ ^ M. <br /> AMOUM OF CCOUh1T.. ...... .$ <br />~ oul <br /> ~ <br />AMOUNT PAID .............. ...$ <br /> BALANCE DUE ..... ......... ..$ BY <br /> <br />