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CCerk and -Re corder <br />FREM0 T COUNTY <br />Norm a Haifteld <br />Counrv Clerk & Recorder <br />615 Macon Avenue, Room 102-Canon City, Colorado 81212 <br />Phone (719) 276-7336 Fax(719)275-1594 <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED ) b1tn Y_- 1 F ada °l <br />NAME OF APPLICANT T-_4w eLQ CYq -+- tali Awk _,vc? <br /> <br />permit # M - I g0 ' z <br />DATE OF HEARING <br />NAME OF CONTACT PERSON 1 <br />please pint <br />Please check which box applies to your permit: <br />1Z- I wish to be contacted 30 days after the hearing to pickup the application <br />M 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 />Signatu <br />. ? PC\ <br />?,k <br />• date of dispostion clerk