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I • III IIIIIIIII IIII III • <br />~ 999 <br />RECEIVES and 111 Enclosure <br />Permittee Name: Larry L Chartier ~JUL2~~ <br />Permit No: M-84-040- <br />operation Name; ~~AINED LAND RECUMATIdIV <br />Anniversary Date: CHARTIER PIT ,~~~ ~~.~ oo~„r ,,, <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />J/~ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />1~- Annual Report <br /> <br />~y <br />~ la3l~~~R <br />ovr,~ r°7 <br />r-.~~e <br />