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<br />112 Attachment <br />Permiti:ee Name: Andersen Construction Co. <br />Operation Name: Miaway Gravel Pit <br />Permit No: 80-156 <br />Anniversary Date: October 15 <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 ~ Map <br />Remarks: <br />~i~ <br />Signatures <br />(Rev. 5184) <br />Doc. No, 1805 <br />~~ <br />