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9/Z <br />MOFFAT COUNTY CLERK AND RECORDER / W71 ('e5 <br />221 W. Victory Way <br />Craig, CO 81625 <br />DEC 18 2009 <br />(970) 824 -9104 GRAND J p11/j�' �rO D OFFICE <br />REC��/IATION r�1 , 1ING & SAFETY <br />MINING/ RECLAMATION FORM <br />/Lj _' <br />File Number <br />Drawer Number <br />Return Date �' � <br />Date_ � � 7 <br />Received From <br />Mailing Address <br />21200:' <br />Division of keciamation, <br />mining and Safety <br />r <br />Mining and Reclamation Application for: <br />Name of Pit or mine. <br />Date on w hich insp ecti o n period is Oyer and app ica io n may be retrieved by <br />Applicant: <br />Agent Signature: __-- �--�- ` <br />For: <br />�✓L--� <br />C� <br />Attest: County Clerk or Deputy: _ <br />