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I .. .. <br />Permittee Name: <br />~ Permit No: <br />Operation Name: <br />Anniversary Date: <br />i <br />yam;{ ~ ti', . t; ~ •;~ 112 Enclosure <br />I; W _~ _ •_ <br />Flintkote Company ~ ^ <br />M-77-247- APh~ 2 c 1980 <br />COALDALE QUARRY <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined <br />Land Reclamation Division for annual fees due <br /> <br />Remarks: <br />Annual Report <br />Map <br />Signature <br />G~ <br />