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•~ <br />112 Attachment <br />Permittee Name: Siegrist Construction ~o. RECErVED <br />Operation Name: <br />Permit No: 82-15 a~C ~ ~" 1~~A <br />MINED LAND RECUMAfIDN DIVISION <br />Anniversary Date: December 10 Calo.Dept.ofNaturalResources <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />~ x~ Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />ICI Annual Report <br />~-~ Map <br />Remarks: See letter to MLRB dated December 27, 1984 <br />Signature v ~ December 27,1984 <br />(Rev. 5/84) <br />Doc. No. 1805 <br />