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C~er~ ancC~ecorcCer <br />F2E~40`T COi.1T~- <br />~J~':'-'. F. z.:Ic <br />COLL~:~: Cl~"x ~ R~COCCB: <br />o l ~ ~(zror. ~~:nu:, Reon t03-Czr on CiR, Co:orzdo 3 f? l2 <br />?hone (i I9) =76-7330 Fay (i l9) 37:-,i9, <br />RE: MINING RECLA[IMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED ~ % ~ ~~i -~~ <br />NAME OF APPLICANT <br />permit # ~ /~~ - ~ 7 -7~ (~~~ <br />DATE OF HEARING- <br />NAMF, OF CONTACT P <br />~~v ~>/tH <br />please print <br /> <br /> <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 herby <br />give the clerk's office permission to distroy <br />• date of dispostion clerk <br /> <br />