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<br />11111111111111IIII ~~~ <br />~~~ 110 Enclosure <br />~~ <br />Permittee Name: ~ <br />19$~ <br />i <br />Permit No: pownare Land.Ca~tle A~ G 2 <br />Operation Name: M_g4-101 N11NED LA~J <br />Anniversary Date: Chaparral Meadows NATION DI~~g10N <br />REG~A <br />08113187 <br />Please complete the following and return this form with your fe s and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined Land R clamation <br />Division for annual fees due <br />Annual Report <br />'~]7 ~) <br />Remarks: ~ / C ~l.L. /l,L./~~CZ^-~~t,c „~~e./' ~ <br />~r~ <br /> <br /> <br />~ - ~ ~~ f <br /> <br />I LG`Z~ 7 <br />i <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Signature <br />(Rev. 02/8 ) <br />5257E <br /> <br />