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. . <br />112 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />Colorado Lien Co <br />M-77-301- <br />ROBERTS QUARRY <br />10 / 2 7 / 8 5 <br />Please complete the following and return this form with your fees an~i <br />reclamation data. <br />Enclosed 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: Report to follow. <br />/ -~ <br />ature <br />