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File Number <br />Date 7 - 6- 1 1 <br />MOFFAT COUNTY CLERK AND RECORDER <br />Drawer Number - Z--L- <br />221 W. Victory Way <br />Craig, CO 81625 <br />(970) 824 -9104 . <br />MINING /RECLAMATION FORM <br />Return Date <br />Received From csi= -i O a ,' i '� ®F-.,az) 4 1 �5 <br />J <br />Mailing Address <br />L� 2- tl, C_A) b) ( 2 <br />Mining and Reclamation Application for: <br />For: cf- i- ✓ i <br />( R. 4 6 <br />Attest: County Clerk or Deputy. (XL <br />Name of Pit or mine: L t t..neSini.Jrr° i s <br />Date on which inspection period is over and application may be retrieved by <br />Applicant: -J , ) A OORIE <br />Agent Signature: - -- <br />0 ..-0,}1,-177-1 r'4 ?La) ) —S S 1 cs f.�zc dZ <br />