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112 Enc3S e/� <br /> Permittee Name: La Poudre S & G'"Nc Ov <br /> Permit No: M-83-090- Un <br /> Operation Name: LA POUDRE S & G INC: 1. <br /> Anniversary Date: 01 / 17 / 86 c• <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: It is necessary to obtain the information required <br /> in the annual report from the OnPra+nr. __- <br /> LA POUDRE SAND & GRAVEL, INC. 1122 <br /> 32852 W.C.R. - NO. 13 686-201EI <br /> WINDSOR, COLORADO 80550 <br /> ' 880 82-139 <br /> <br /> <br /> orado Mined Land RLclamation Division $ 350. 00 <br /> of <br /> Three Hundred Fifty Dollars and no/100 ------------------ Dollars <br /> C,WF N the FIRST NATIONAL <br /> B BA/17C of R7NDSOR <br /> r.o.eoz vov,wiNosoz,caox.00 eosso <br /> M 83-090 LaPoudre S&G Inc. �-.-- <br /> For <br /> ' ii'00 I, L 2 211' I: 10700 L 39 71: 20 604 >,ii' —E-2 <br /> Signature // <br />