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JAKE KAUFFMAN & SON INC <br />000000000 <br />Division of Reclamation, Mining, and Safety <br />Fee Receipt for M1999069 <br />Receipt #: 14337 <br />Date: 12/28/2012 <br />Permit: M1999069 <br />Payment Method Revenue Code <br />Fee Description /Notes <br />Amount <br />68825 <br />4300 -01 <br />Minerals Annual Fees <br />M- 1999 -069, CMB <br />$791.00 <br />Receipt Total: I $791.00 <br />Page 1 of 1 <br />