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Clerk a n d R e c o rde r <br /> Justin A Grantham, County Clerk & Recorder <br /> 615 Macon Avenue, Room 103 Canon City, Colorado 81212 <br /> Phone 719.276.7332 <br /> Fax 719.276.7339 <br /> 'ustin.zrantli am(a�,fremon tco.com <br /> RE: MINING RECLATMATION PERMIT <br /> APPLICATION COLO STATE 34-32-112.10.8 <br /> DATE RECEIVED <br /> NAME OF APPLICANTcR��Tot-� <br /> PERMIT # <br /> DATE OF HEARING <br /> NAME OF CONTACT PERSON: <br /> "-. V-S�� phone # <br /> please print <br /> L c,- Te-t:12� -j- I-. mn <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 <br /> herby give the clerk's permission to destroy <br /> oN,v co <br /> ��XX X Signature <br /> * SEAL <br /> �o�oM • Date of Disposition \0 -Z-1 Z02.0 Clerk'-2--a y� <br /> UAHistory FileTorms\reclamation form.doc <br />