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~~ c~ • • <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 / 85 <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: <br />Signature <br />