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i <br /> <br /> <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />Asphalt~!aving Company <br />M-83-084 <br />Tomah Site <br />11/08/88 <br />~~ <br />111/112 Enclosure <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />x Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />x Annual Report <br />x Map <br />Remarks: See attached reyort. <br />S <br />(06/88 ) <br />0054f <br />