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i <br />_ • y • <br />111/112 Enclosure <br />Permittee Name: <br />Permit No: Exxon Co USA <br />•_: Operation Name: M-80-041 <br />.:; Anniversary Date: Colony Shale Oil PRO <br />11/01/8$ <br />Please complete the following and return this form with your fees and <br />reclamation data. ~ •• <br />Enclo/sed are: (Check space(s) below) <br />/ Check or money order payable to Colorado Mined land Reclamation <br />Division for annual fees due <br />Annual Report <br />Map ~ " ;',? ~~ ~_ <br />Remarks: SEE /4TTA~itEa LE?TElZ • <br />(Rev. 02/87) <br />5257E <br /> <br />