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•~ <br />111/112 Enclosure <br />Permittee Name: r '~;°~=~',v,;, <br />Permit No: Asphalt Pa vin Co f'"' ~-~ ~~, ~ ~h,. "`~ <br />g ;~' .:. ; i~ :: <br />_: Operation Name: M-83-089 "'' ~~~` <br />_. Anniversary Date: Tomah Site X10 V 1 U 1987 <br />11/08/87 !~ti~tL~ ., , <br />C~ECL ~ i lk,.~ <br />Please complete the following and return this form with your fees'~~Y}~.iN J}i,J,, ,pry <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />x Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />~_ Annual Report <br />x Map <br />Remarks: See attached report <br />Signature <br />(Rev. 02/87) <br />5257E <br />