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~ S <br />._ ,; <br />RECEIVED <br />Permit No: 77-140 JAN 241983 <br />Ann_'versary Date: ~dT1Ud1'V <br />MINED L4ND RECLAMATION <br />COLO. DEDT. OF NATURAL RESOI:RCES <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />heck or money order payable to Colorado Mined Land Reclama- <br />tion Division for annual fees due <br />Annual Report <br />Map <br />Signed, <br />~ ~'~ r'.T <br />,~ ~' <br />