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• III IIIIIIIIIIIIIIII • <br />L-,si~~,(~~(~,% ~,Dclosure <br />Permittee Name: Coulson Excavating Co., Inc. ~®~ 2 O S~@J <br />Permit No: M-79-059 <br />Operation Name: Brownwood Pit P~JeM~~LA~f® <br />Anniversary Date: 11 / 20 / 86 RECLA~A~10~ ®!l,9SIOR <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclcsed are: (Check space(s) below) <br />X Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />~ Annual Report <br />X Map <br />Remarks: ~ ~ /~NJJnr-_ ~,~,~ <br /> <br />. ~% ~i ~~a/~6 <br />Si ature °x'11 ~~~" <br />~~ <br />~~ <br />