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~ ~ III IIIIIIIIIIIII III <br />R~C~IVED 999 <br />112 Attachment <br />Permittee Name: Andesite Rock Co. DES 2 41984 <br />Operation Name: AIINEDLANpRECIAMATIONDIVI91DPl <br />o. ept. Of Neturel Aeaources <br />Permit No: 77-141 <br />Anniversary Date: _December 29 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />I$I Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />~-~ Annual Report <br />I_I Map <br />Remarks/: nJ.tJr/la,/~ /c o/~ ~ ~~--`J2.1z /D <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1805 <br />