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g <br /> <br /> MINED LAND RECLAMATION DIVISION N~ 18234 <br />1313 Sherman, Rm. 215 - <br />Denver, Colorado 80]03 -• DA7E ~ " 3 ig ~a <br /> RECENED {~~303)nn 866-3567 __~ <br />$~ <br /> FROM ~Y hl..~l ~9B <br />Onl~Il.QI <br />, ~.~, <br /> (1f~~II <br />!<lJ~ l3'\T'111.!~Lk~ ,R'~O/ .( ~, i~GS! `d' ~~~'-~'DOLLARS <br /> <br /> 1 /p- u CASH <br />FORQ~`1~0~ K.i-~o~'/c~~ "CHECK <br />" ~S 1 3 d M <br />O <br />' <br /> . <br />. <br />- <br />~j <br /> AMOUNT OF ACCOUNT...... ....$ (^~°~I'~~ o/,~ <br />I, `/ <br />y' <br />~ <br />AMOUNT PAID . .. .......... .. $ <br />~~i`~' 1 ll <br />_ IC <br />` <br />I <br />l <br />BALANCE DUE ... ... ........$ BY <br /> <br />