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., _ • IIIIII'lllll"IIIII <br />110 and 111 Attachment <br />Permittee Name: Bear River Sand & Gravel w ~1 <br />Operation Name: /r~~+~,~/~D <br />Permit No: 77-519 D~`G- 1~ <br />Mty~UN ¢ ~®64 <br />Anniversary Date: August 28 ~o/p~p~R~,UM <br />of ~ftOH <br />Net~~otgeroptet c ON <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />i4' Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />I_I Annual Report <br />Signature <br />(Rev. 5/84) <br />Doc. No. 1782 <br />.\ <br />