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Lakewood Brick & Tile Company <br />000000000 <br />Division of Reclamation, Mining, and Safety <br />Fee Receipt for M1975009 <br />Receipt #: 13800 <br />Date: 09/28/2012 <br />Permit: M1975009 <br />Payment Method Revenue Code <br />Y , ._.,a.. Fee D Cription /Notes � Amoun <br />101786 jwd <br />4300 -01 <br />Minerals Annual Fees <br />M- 1975 -009, Paid By Summit Brick Company <br />$323.00 <br />Receipt Total: I $323.00 <br />Page 1 of 1 <br />