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C~er~ c~~zc~~,ecorcCer~ <br />FRE_~IO~T CUC~;TY' <br />\a-.a F.~:d:Ic <br />bl: i~tacor, a~.enu:. Room l43•Czcon CIr<', Ccloiado 31312 <br />Phc~e (i i9) _75-".36 fay {i l9) 37~-i~9~ <br />Rf:.MINiNG RfCLATMATION PERMiT APPLiCATiON <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED ~//' ~~f "~~ <br />NAME OF APPLICANT <br />.permit # ~ {~ - ~~ '7~' ~ ~/ <br />DATE OF <br />CONTACT <br /> <br />Please check which box applies to your permit: <br />I wish to be contacted 36 days after the hearing to pickup the application <br />~ I do not wish to pickup the application 30 days after the hearing and herby <br />give the clerk's office permission to distroy <br />Signatu <br />• date of dispostion clerk <br />