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Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br /> <br />111/112 Enclosure <br />~1 <br />J <br />Cooley Gravel Company <br />M-76-009HR <br />Menzer Quarry <br />06/23/88 <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 pdyable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />. ~ / Annual Report <br />`~ Map <br />~~ • ~ <br />Remarks: ,. ~ ~ <br />~/.~/fr8 , ~.~~,~~ <br />Signature <br />(Rev. 02/88) <br />5257E <br />0054f <br />