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110 and 111 Enclosure <br />Permittee Name: <br />Permit No: Schmalz Const Ltd <br />Operation Name: M-84-069- ~~~~~_ ~ 186 <br />Anniversary Date: SCHMALZ CONST PIT <br />07 / 12 / 86 <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 #so oa <br />_~ Annual Report <br />Remarks: <br />MINED LAN. .ECLAMATION DIVISION. nJ o a.J 7 6 O 6 <br />1313 SYierman, Room q23 " p <br />Denver, Colorado 80203 DATE v ~ is _3_/Q <br />(303) 8 6-3567 n /J <br />RECEIVED FROM 5~~~ QJ ilY~ fill T~ ~{~~ <br />THE SUM OF ~ DOLLARS $ 5 ~~• ~V <br />FOR L~(Yl/Vl TAP ~~~~~"'~ OR~ OrHOCK <br />AMOUNT OF gCCOUNT...... $ <br />AMOUNT PAIO ................ $ <br />BALANCE OUE ............... $ <br />~tiQh~Q ~Oul <br />BY ~ ~ ~/f /V~l <br />Signature <br />`7 /ti/8~ <br />~'1. ~ ~ <br />~ lQ <br />