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<br />112 Attachment <br />Permittee Name: <br />Operation Name: <br />Permit No <br />Coulsen Excavatino Co.. Inc. <br />Anniversary Date: NnvamhPr 9(1 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />I~ ~ <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report , ~ // ~ ~~e~ ' P--,, ~,r, <br />~~ Map cii~"~~~ <br />Remarks: /', ~~r.6. S; ~ ll..f_Jc,P,Q, llict ~ ~ 4iY'v~ <br />~i . ~, <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1805 <br />