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CCer~ ancC~Z,ecorcCer <br />FREMONT COLI+TY' <br />~~orna Ha~iizld <br />Count- Clerl Nc Rzcordzr <br />6l ~ blawn Acznuz, Room 102-Canon Cite, Colorado 8I2I2 <br />Phonz (7l9) Z76-T36 Fay (i 19) 275-li9d <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLD STAT. 34-32-112.10.8 <br />DATE RECEIVI <br />NAME OF APP <br /><3--- <br />permit # ~ C~o3`~ <br />DATE OF HEARING~~z~t- 0`~ <br />NAME OF CONTACTQPER1S N <br />~'~~ l~-e.-(,l /h y~-tzyy~ Phone # ~~ ~ -`~i ~ ~ l <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 />Q I do not wish to pickup the application 30 days after the hearing and herby <br />give the clerk's office permission to distroy~ ~^ / J <br />Signature ~~~~U /\ /x~-~-'CPr/~~~~ <br />• date of dispostion clerk <br />