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<br />Form 5510-1~ ~ - ~ UNl•1'ED STATCS. ~ .• ~~ ~ ~ --,f'ORI:1 e1PPROVID..
<br /><october 15751 Ui'pARI'MENP~OF 9"HC,IN tLR1012 ~• ~ onlu.mo. oz_aon~is ~.
<br />' QUi2EAU,¢R- LAND MANAGE67L'•N1 _ ,
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<br />'.5(~ , `~~ •• ~VL=C~ETATIVi3 OR.MINCRAL MATERIAL ~ ~ Uix•-trictr' ~alt~ .__.
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<br />Name o€ applicant ,: Hddces~. (include zip. code) --
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<br />Jcclcr.ou Co'ari~y Road ~ Uridt;e 1)op3a:tment l'lelden~..Gu'lol'edD i3U0.t)0
<br />lCiud~ot, materiol ' ' ~ .. ~ ~ -- estimated quantity'
<br />Give legal loud descriptaac .. ~ ~ •. ,
<br />'1~ y CJ lt`78 w : ,.' . 20 ....: std .': '. v .... ..:..:
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