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VOTE 1�DRI <br /> .`RE°DCM COL:N7 <br /> ' • rj <br /> • <br /> 1 <br /> Off ice of tfie e&A and q""de i <br /> MINING RECLAMATION PERMIT APPLICATION <br /> CRS 34-32-112 (10)(a) (Filing Only) <br /> Applicant Name U _(' . ®ate Received <br /> Permit # �~ <br /> ®ate of the Nearing <br /> Contact Name and Phone #: <br /> Name: Phone # 11q -�L Cltr� <br /> please print <br /> Please check which box applies to your permit: <br /> ❑ I wish to be contacted 30 days after the hearing to pickup the application <br /> I do not wish to pickup the application 30 days after the hearing and I hereby give <br /> the Clerk's Office permission to destroy this filing <br /> Signature 4,�, <br /> A O� o` g Clerk: , QA' i7 g Date of Filing 2 � <br /> &A, 7imUn 0 <br /> o g J%ecs�cc <br /> 615 Atacwt aue Sam 1V2110 <br /> ea&m e4, W 81212 (719)-276-7332 jwtin_gcs nMamCafurraantw.cm <br />