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MOFFAT COUN-1 Y LLtKK AIMIJ rccwKUr -M <br />221 W. victory way <br />Craig, CO 81625 <br />(970) 824 -9104 <br />MINING/ RECLAMATION FORM <br />File Number I S S <br />Drawer Number <br />Return Date A 43US+ `+ <br />A- .;),C, k q <br />Received <br />Mailing Address <br />Mining *and Reclamation Application for: <br />Name of Pit or mine: <br />Date on which inspection period is over and application may be retrieved by <br />Applicant: <br />Agent Signature:-----,,'- <br />ignature: ; <br />For: <br />Attest: Coun ty Clerk or Deputy.: ��► V \-�� <br />