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-~ .~ - ~ ~ iii iiiiiiiiiiiuiii <br />' 110 Enclosure <br />Perini ttee Name : ~ ~ C/ ~ ~ !! E <br />Permit No: Walsenburg S&g Inc <br />Operation Name: M-78-283 ~dAY 1 3 1987 <br />Anniversary Date: Sand Arroyo <br />04/24/87 MINED LAND <br />REC~AMAT!ON DIV131ON <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 Land Reclamation <br />Division for annual fees due <br />Annual Report <br />~ - ~ - <br />Signature ,,~~ ,,~ _ .~; ~~ <br />(Rev. 02/87) _ <br />5257E t- . r <br />