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<br /> <br />110 and 111 Attachment <br />Permittee Name: Charles Devereux <br />Operation Name:. <br />Permit No: 78-209 <br />Anniversary Dates August 14 r <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />-~ <br />~s!' Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due , <br />~-~ Annual Report <br />Remarks: P1~ _._ ,_ ,;,e *,..~,.r•s~ <br /> <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1782 <br />