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_,, <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />~~ <br />111/112 Enclosure <br />~~ <br />Siegrist Const Co <br />M-82-015 <br />Siegrist Const Co <br />12/10/87 <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 />Dl vision for annual fees due <br />x Annual Report <br />x Map <br />Remarks: (Please see attached letter) <br />Signature RoberC L. Siegrist, President <br />SIIX3ZIST CONSTRUCTION CO. <br />(Rev. 02/87) <br />5257E <br />