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a <br />110 and 111 Attachment <br />Permittee Name: Marvin E_ Rrnwn <br />Operation Name: <br />Permit No: R9-9nn <br />Anniversary Date: November 19 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />~~ Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />I_I Annual Report <br />Remarks: <br />~~ <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1782 <br />