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~ III IIIIIIIIIIIIIIII <br />Permittee Name: Fern and Keith Holsinner <br />Operation Name: <br />Permit No: 80-52 <br />Anniversary Date: April 9'~ <br />• <br />~~, ~~ <br />110 and 111 tachment ~i <br /> <br />lIPF21"135 <br />. ~.. <br />(, .. ,. , . t,.. . , <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />~-' Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />~ ~ Annual Report <br /> <br />Si <br />(Rev. 5/84) <br />Doc. No. 1782 <br />