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r • <br />~II ~I~~I~II~I~~~ ~~~ <br />f <br />Please complete the following and return this form with your fees <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />,. <br />~ `` <br />aaa <br />112 Attachment <br />Permittee Name: J & M Schmahl //~~ -. <br />Operation Name: p,Sn /~ /JC ~ (~~i,~dJ/INy <br />Permit No: M-84-001 ~ ~ ~~~'+~~ <br />,. <br />Anniversary Date: April 4 " ' '" "' <br />I_I Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />I~ Annual Report <br />I~ Map. <br />Remarks: ~'~nvc.~ ~ <br />signature <br />{Rev. 5184) <br />Ooc. No. 1805 <br />