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• iii iiiiiiiiiiii~iii • <br />999 <br />111/112 Enclosure <br />Permittee Name• Mathias Concrete Inc ~~-'" " `- `~ ~ <br />Permit No: M-77-140 JAN 1° 1°87 <br />Operation Name: N Farm Rd Pit No 1 <br />Anniversary Oate: O1 / 15 / 87 Iy~jlyrp ~.ArWO <br />REGLANATIOPv OfvISlOR <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Encius2o are ~;Cneck space(si beiowi <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Map <br />~/~~~"7 <br />Signature ~. ~ /~Q~ <br />(~ <br />