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<br /> <br />112 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />Braley S&g <br />M-80-020- <br />BRALEY S&G PIT NO 1 <br />0 7 / 15 / 8 5 <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 /> <br />Annual Report <br />Map <br />Remarks: <br />Signature <br />