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Belvedere Stone, LLC <br />000000000 <br />Division of Reclamation, Mining, and Safety <br />Fee Receipt for M1991147 <br />Receipt #: 13821 <br />Date: 10/02/2012 <br />Permit: M1991147 <br />Payment Method Revenue Code <br />Pei Description /Notes Amount <br />1017 <br />4300 -01 <br />Minerals Annual Fees <br />M- 1991 -147, CMB <br />$323.00 <br />Receipt Total: 1 $323.00 <br />Page 1 of 1 <br />