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4 1 <br />..~ ~:~. <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br /> <br />r _ ,.,,. <br />Nickolaus Arnusch <br />M-81-2a~ <br />Arnusch Grav Pit 3 <br />02/25/89 <br /> <br />110 Enclosure <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 />Signature <br />(Rev. 06/88) <br />0052f <br />