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_, : . <br />~II ~II'I~~IIII~~III <br />Permittee Name: Jim Helmericks <br />Permit No: M-85-001- <br /> <br />110 and 111 nclosure tj <br />Operation Name: ~ g ,] pit <br />Anniversary Date: 06 / 27 / 86 JU~ 2 A 1986 <br />Please complete the following and return this form with your fees afl~ ~ - . <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />•3~Lov,~ i <br />Annual Report <br />Remarks: ~~~ \ !J i ~ G ~ ~ U/~ <br />~ J L <br /> <br />Signature <br />~ r~~~~ <br />~-~ ~ <br />,-~~ <br />