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<br /> <br />112 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />Farmers/bank Of Brush <br />M-80-135- <br />HEADLEY FARMS <br />10/07/85 <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 />~ Map <br />Remarks: jig 4u .~i~ ci.t~,...'l-- 1i __~~1~ '/«~C~r ~, t~-~-. <br />/ /- t • -~ C /'.r, 2i. t.7 •. ~, /2 L~- i -t r K. t-t _ u <br />TJ <br />,~ , i <br />2 +z ~~~ ~/. -i. ,)i. tA~l1 t.~,.~d t~.~ ~.2r;z.7! ~Y- L/~ tc~I'r~J <br /> <br />~,, <br />"`" <br />'~77 _ ~ ,~ ~~ ANA ~,~~;i <br />~~rt.~,-,, /~`~ Ga-Q; ~ ~~,a~ of ~~+'urai esaA ~f~ N <br />Sign <br />