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iiiiiiiiiiiii j <br />Permittee Name• Mathias Concrete, Inc. <br />Operation Name: <br />Permit No: 77-140 <br />Anniversary Date: January 15 <br />~~r~ <br />112 Attachment <br />RECEIVED <br />JAN 17 ~~~; <br />GAINED LAND gECLAMAYION DIVISION <br />Colo. Dept. of Natural Resources <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 />I_I Annual Report <br />I_I Map <br /> <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1805 <br />i/i~~~s <br />GYYI - ~ ~" <br />~; C~ <br />