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• ~ iii iuiiiiiiiiuiii <br />999 <br />T10 and 111 Enclosure <br />Permittee Name: <br />Permit No: Western Slope Con Co <br />Operation Name: M-83-209- <br />Anniversary Date: BENTON DAWSON GRAVEL <br />07/25/86 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />~/ ~' - <br />f/ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br />• <br />1~ <br />~ t! :~c' <br /> <br />•~" / ~h l~ ~ ~'~ lit'/ 7 <br />J~ ~ <br />~. - <br /> <br />r 1 0 l~$o" <br />i gnature-- ~~ ~'z- <br />~~c-c~ ,.;rte. / ~ tl.u r.~~'> <br />~C` / ~~ <br />~ ~ ~,~~~ <br />~~--- <br />