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<br /> <br />112 Attachment <br />Permittee Name: Coulson Excavating, Co., Inc. <br />Operation Name: <br />Permit No: 78-53 <br />Anniversary Date: November <br />Please complete the following and return this form with your fees and <br />rec]amation data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />I_I Annual Report <br />I_I Map <br />Remarks: ,~~ ,,~,r~.e. ['~°Qirt.l'a /jpQ/,f c"~~~ ~,~~ I - / Zf~~ <br /> <br />~~ <br />Signature <br />(Rev. 5/84j <br />Doc. No. 1805 <br />