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~" ~ ~~~~~~~~~~~~~~~~~~~ ~ f~ECEI\!E® <br />JUL s ~saz <br />~c <br />Permit No: 76-20 <br />MINED LAND RECLAMATION <br />Anniversary Date: May z7 Colo. Depi. of Natural Reso~~rce= <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />£n closed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />® ti on Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />Signed, <br />~.~a, ~v~„r.,aR.~. <br />