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,~ <br />Permittee Name: <br />1 Permit No: <br />Operation Name: <br />Anniversary Date: <br />I 1 <br />LJ <br />Suburban Sand and Gravel <br />M-79-195 <br />Road Runners Rest II Pit <br />01/28/87 <br />112 Enclosure <br />Please complete the following and return this form with your fees <br />and reclamation data. <br />Enclosed are: Check space(s) below <br />-X~ Check or money order payable to Colorado Mined Land Reclama- <br />tion Aivision for annual fees due <br />_~~ Annual Report <br />Map <br />Rem' - <br />MINED LAND RECLAMATION Dr-~N <br />1313 Sherman, Room 423 <br />_ Denver, Colorado 80203 <br />(303) 866-3567 (' <br />RECEIVED FROM ~ ~ I 1 S~ ~ !~ \ <br />~ ~ THE SUM <br />_ FOR _~yl . ~~, ~ ~ ELI _ L <br />AMOUNT OF gCCOUNT...... $ f <br />AMOUNT PglO ................ $ <br />BALANCE DUE ............... $ <br />N° 00850f~8/-~ <br />DA ~'19 i1 / <br /> <br />_ ^ <br />cn <br />s+ <br />~~ ~ <br />~ <br />" <br />uv+E CK <br />` ^MO <br />'Hanle ~ou I <br />Signatur€ ~ / Dean Craft <br />