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MOFFAT COUNTY CLERK AND RECORDER <br />221 W. Victory Way <br />Craig, CO 81625 <br />(970) 824 -9104 <br />MININGI RECLAMATION FORM <br />r: <br />File Number -,Y, / � 0 <br />Drawer Number. <br />Return <br />Date q-aq -I -,� <br />Received From 10 <br />Mailing Add <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 Si ature: <br />For: Co %w yro <br />Attest: County Clerk or Deputy: <br />