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s iii iiiiiiiiiiiii iii <br />Permit No: A]-AD <br />Anniversary.Date: ~1ay ~7 <br />Operator: Tezak Const. Co., Inc. PD•Bo~t 39~ Co~o)D~C~,~0.~~3~~ <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to the Colorado Mined Land <br />_ Reclamation Division for annual fees due <br />_ Annual Report <br />Remarks: <br /> <br />Signature Q ~\ 5/~a ~~-~ <br />'~1 f kan~ ~~~ <br />e ,~n~,[e <br />/1 rr n u c ~ r¢/a ~ i.f>(l <br />~~.n¢ i ~. <br />~, ~ • ~` <br />~~ ~~ <br />