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E `r • • ' <br /> VOTE <br /> MAi(E FREEDOM COUNT VIEW <br /> • <br /> cgg&e of ffw fee& and J`'�ewydu <br /> MINING RECLAMATION PERMIT APPLICATION <br /> CRS 34-32-112 (10)(a) (Filing Only) <br /> Applicant Name EA L 0Ar �� Date Received 3' /7- <br /> Permit # <br /> Date of the Hearing <br /> Contact Name and Phone #: <br /> Name: �s Phone # <br /> please print <br /> Please check which box applies to your permit: <br /> [ J I wish to be contacted 30 days after the hearing to pickup the application <br /> ❑ 1 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 <br /> Accepting Clerk: � �- Date of Filing 3 z/ '7 ,2i <br /> ptin <br /> 5:wnant cawttq Uex& and geavid" <br /> 615 Atac am Suite 102110 <br /> eahm eug,ev 81212 (719)-276-7332 jWUh.9car AWWn&0"M <br />