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<br />~or,-na E{atfield <br />CounR~ Clerk &: Recorder <br />FREMO~T COLtiT~' <br />CCer~ ancl2~.ecorc~er <br />61 ~ itilat:on Avenue, Foom 102-Canon Ciro, Colorado 81212 <br />Phone (719) 2 i6-7336 Fay (719) 27~-1~9~t <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED `7~`1H~i .~~~, ~©~~~ <br />NAME OF APPLICANT~o2.T~~i~1o /~i~-iC.i/~~L.5 <br />permit # <br />DATE OF HEARING <br />NAME OF CONTACT PERSON <br />Phone # <br />please print <br />Please check which box applies to your permit: <br />[y~ I wish to be contacted 30 days after the hearing to pickup the application <br />~] I do not wish to pickup the application 30 days after the hearing and herby <br />give the clerk's office permission to distroy <br />Signature ~~-_-... `~Gc~.-~ :~ 7s - 3~is"l <br />• date of dispostion <br />clerk <br />• <br />