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• • <br />~~ <br />M;NED L,aND RECLAMATION DIV. _~N ~J a 0 0 5 5 <br />1313 Sherman Street Room 423 <br />Denver, CO 80203 `~ <br />lin21 RfiftiSfi7. n OATE~_~_'Is <br />gECEIVEO <br />THE SUM ~ ~' OLLARS /$j`y~/1SL~ <br />AMOUNT OF ACCOUNT...... $ <br />AMOUNT PAID ................ $ <br />iii - i i i i i i i i i i ii -i~ <br />' I BALANCE DUE ............. $ BY T--/'// / G~~~ l ~ I' <br />