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<br /> <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />• <br />110 and 111 Enclosure <br />C~ <br />Fred L Korinek <br />M-79-131- <br />KORINEK S&G PIT <br />07 / 27 / 86 <br /> <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: {r_heck space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />~_ Annual Report <br />