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<br /> <br />Permittee Name: <br />Permit No: <br />Operation Name• <br />Anniversary Date <br />~~~(~~losure <br /> <br />Farnsworth Const <br />M-82-154- <br />11~/S05R/H85R PIT 2 <br />• <br />6~OV ~ ~d <br />I1~1~~ (~~~ ~f'~i'~~A~Q~~ <br />CO10. ®8p1.Of N1821i7ftl R6SOOfCOS <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: -(Check 5pace(-s) below) <br />w~,/ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br /> <br /> <br /> <br />Signature <br />gNl•~•~'d <br />~~~¢ <br />