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MOFFAT COUNTY CLERK AND RECORDER <br />221 W. Victory Way <br />Craig, CO 81625 <br />(970) 824 -9104 <br />MINING/ RECLAMATION FORM <br />File Number <br />Drawer Number <br />Return <br />Date •• v <br />Received From 1 -� �� fl ° i2 n rr% - 12009 <br />Di,*i©n of Reclamation, <br />Mailing Addres l a i no a nd safety <br />Mining and Reclamation Application for: <br />Name of Pit or mine: <br />Date on which inspection period is over and application may be retrieved by <br />Applicant: 6 " o►..rEkS <br />Agent Signature: <br />For: Y�1 ri —✓� i ,`� T` <br />-4 r\ S S A v ►-� �c"� S <br />9/ <br />Rtf <br />DEC 14 2009 <br />GRAND JUM, : t� � d �� 1L.-L) OFFICE <br />�I; > <br />DI>=J(\1 OF <br />RECLAK4ATI()N i .(?tili!G & SAFETY <br />Attest: County Clerk or Deputy: <br />