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CCerk and T ecorder <br />FRE?MO T COL-NTTY <br />for na Hacfie(d <br />Coun:? Clerk &- Recorder <br />6I6 Macon Avenue, Room 102-Canon Cirv, Colorado 31212 <br />Phone (719) 276-7336 Fax (719) 276-169, <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />CO LO STAT. 34-32-112.10.8 <br />DATE RECEIVED 401 6 <br />NAME OF APPLICANT dz'- <br />permit # ?L( <br />DATE OF HEARING <br />NAME OF CONTACT PERSON _ <br />?I`Y?G1 ?' l ?Gt VyLWl Phone please priM <br />Please check which box applies to your permit: <br />[Z 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 <br />® date of dispostion <br />clerk <br />U -