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xh; G,,f Z <br /> VOTE <br /> qr= of ffw e&t& and J <br /> MINING RECLAMATION PERMIT APPLICATION <br /> CRS 34-32-112 (10)(a) (Filing Only) <br /> Applicant Name Date Received S-- /7- <br /> Permit # <br /> Date of the Hearing <br /> Contact Name and Phone #: <br /> Name: 1�` L�� s Phone # 7 Iq <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 /> ❑ 1 do not wish to pickup the application 30 days after the hearing and 1 hereby give <br /> the Clerk's Office permission to destroy this filing <br /> Signature <br /> Accepting Clerk: � "� Date of Filing 3 1 <br /> pan <br /> ,iwma.nt Caun # Cte& and 9ec44deu <br /> 615.Atacan Clue Suite 1021103 <br /> eanmz eU&t, W 81212 (719)-276-7332 �ftwW.y"udRam@fwmon& cam <br />