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MOFFAT COUNTY CLERK AND RECORDER <br />221 W. Victory Way <br />Ext-tt 13 iT Craig, CO 81625 <br />(970) 824 -9104 <br />File Number 75,2 <br />Drawer Number <br />Return Date <br />Date <br />MINING /RECLAMATION FORM <br />� Inon+E,S <br />/1, 20(3 <br />Received From gCLrU -mAA- ( <br />Mailing Address <br />Mining and Reclamation Application for: <br />Name of Pit or mine: <br />Date on which inspection period is over and application may be retrieved by <br />Applicant: <br />Agent Signature: z' 1' `� <br />For: <br />Attest: County Clerk or Deputy: <br />.24. // (161711../1-tate-vt, <br />