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~'orna Haifizld <br />Couno. Clzrl R Rzcordzr <br />Clergy anc~Recorcfer <br />FREMOtiT COL~T7" <br />6f ~ ~(acon Avznuz, Foom I02-Canon Ciry, Colorado 3 1212 <br />Phonz (i l9) ? i6-7336 Fay (i l9) 275-159 <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED ~~ ~ /~ <br />NAME OF <br />permit #~33-l1~ I <br />DATE OF HEARI <br />NAME OF CONTI <br />Phone t <br />please prin! <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 />Cj 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 /> <br />~-~ <br /> <br />• date of dispostion clerk <br />