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~._. <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br /> <br />112 Enclosure <br /> <br />Robinson Brick Co <br />M-78-014- <br />North Chieftain <br />08/14/86 <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 <br />X Annual Report <br />Map <br />Remarks: <br /> <br />gnature <br />