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. ~o <br />Permittee Name: <br />• • III IIIIIIIIIIIIIIII- • • <br />999 111 /112 Enclosure <br />Permit No: Jake Kauffman d Sons <br />Operation Name: <br />Anniversary Date: man <br />5/14/87 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />'~ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />,JL Map <br />Remarks: <br />(1 c 1<'c ,. ' ~J ~ . t ~~nu oc~ ~ c z ~c c ~ ~t~ ~mal~: n. ~-rln~o , ~-ihat <br />.~-4~c , ~^c~c.rl -,~,~_~~~~ ~~~~ ~~,k~,.a hart cZ. 5icce~.Q~~ r,A~ <br />~~ ~`'I~ -~hnt ,~ c , Ate. a: h~Rm - ~ hin! ~M'\ ~#6~9, l.clRCrflc~_ <br />,~.K ~~ c°dt SAD rd .I~c~£' c'n i ~.~, -(~ H ~ n n l_i ~' ;niQ .. <br />.~ - - <br />c ~-: <br />Signature <br />(Rev. 02/87) <br />5257E <br />