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M , ~~ <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />Mowbray Gravel <br />M-79-166 <br />Mowbray Gravel Pit <br />09/04/87 <br />~ iii iiiiiiiiiiiiiiii <br />~~°~~ vl~~closure <br />Sr_P 17198T <br />MINED LAND <br />RECLAMATION DIVISION <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />!~ ~ d <br />~o Check or money order payable to Colorado Mined Land Reclamation <br />Div~cion fer annual fees due <br />Annual Report <br />Remarks: Thare hey ?peen nothing t~l.en out of this; gravel nit <br />this n~~t year <br /> <br /> MINED _ JD RECLAMATION DIVISION n- Q Q 6 8 4 5 <br /> 1313 Sherman, Room 413 _ <br />Denver, Colorado SOld3 <br />~7 <br />T <br />~ ~ i <br /> DA <br />E <br />s <br />(30386,6-3567 <br /> RECEIVED FROM L~11 ~/ / ~ TL > ~~. <br /> ~ OC/ <br />O ' ` L/ <br /> THE SUM OF <br />DOLLARS $ <br /> f l ~7 Q I - ^ G4SH <br />FOR ~~ ~-~(' ~ ~ l ! ~ ~ ~ t4. ~ ~i ~ /~r.,i.a cK <br /> AMOUNT OF ACCOUNT...... $ <br />kanle oul <br /> AMOUNT PAID ................ $ <br /> BALANCE OUE ............... $ BY <br /> <br />Signature <br />(Rev. 02/87) <br />5257E <br />