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•. <br /> <br />112 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />CBW Builders Inc <br />M-80-080- <br />Una Pit <br />07 / 24 / g7 <br />C,`i~" S~~~~ <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />XX Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Map <br />Remarks: No mining or reclamation activity at pit in past 12 months. <br />Signature <br /> <br />