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110 and Ill Enclosure <br /> Permittee Name: Hallenbeck Const Inc <br /> Permit No: M-77-062- <br /> Operation Name: Hallenbeck Pit No 1 <br /> Anniversary Date: 04 / 02 / 85 <br /> Please complete the following and return this form with your fees and <br /> reclamation data. <br /> Enclosed are: (Check space(s) below) <br /> K Check or money order payable to Colorado Mined Land Reclamation <br /> Division for annual fees due <br /> Annual Report <br /> Remarks: <br /> MINED,LAND RECLAMATION DIV1 I N 2 3829 <br /> L:13 Sherman Street Room 42t <br /> Denver, CO 80203 DATE 19 <br /> (303 866-3567 <br /> RECEIVED FROM <br /> THE SUM OF <br /> — DOLLARS $ �'S� <br /> ❑Ga9i <br /> FOR <br /> 7_ }ECK <br /> AMOUNT OF ACCOUNT...... <br /> AMCXJW PAID................$ <br /> .DUE...............$ BY <br /> s <br /> Signa ure <br />