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• <br />C. <br />110 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />Andersen Const Co <br />M-77-053 <br />Lyle Smith Pit <br />12 / 23 / 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 />~/ Annual Report <br />Remarks: <br />o~ ~~.~~,L'~~ <br />Signature <br />