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iii iiiiiiiiiiiu iii' <br />e <br />Permittee Name: <br />/ Permit No: <br />Operation Name: <br />Anniversary Date: <br />Mathias Concrete, Inc. <br />M-77-140 <br />N Farm Rd Pit No 1 <br />01/15/89 <br />~. <br />111/112 Enclosure <br />-w fr~ ~~ [? M ,~ Ems' ;~ <br />aura ~ s 1989 <br />I/lZs:D IJii~ID <br />t-itC'-<+IVi/a i I ~N DIVIStOIiI <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: ck space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due ~~50,vo <br />Annual Report <br />Map <br />