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iii iiiiiiiiiiiiiiii • <br />110 Enclosure <br />.. <br />i <r <br />Permittee Name: i-~ <br />Permit No: Ron Ebberts ~~fl~ o <br />Operation Name: ,;, - 1~~ ~g87 <br />Anniversary Dat~,80-038 <br />isappointment Valle <br />10/O1 /87 ~ ~~' " <br />;r~~if, <br />d <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />_ _ Di.v_ision for annual fees due - - - - <br />!~ Annual Report <br />Remarks: <br />Signature <br />(Rev. 02/87) <br />5257E <br /> <br />