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III IIIIIIIIIIIIIIII ~ ~ ~ _~~ <br />7 <br />.~~:,_ <br />Permit No: 77-i6 <br />Anniversary Date: July 5 .-~.,. 1 ;~ ~9~Z <br />I i ~~ - .. i.^(~r <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 />Check or money order payable to Colorado Mined Land Reclama- <br />tion Division for annual fees due <br />Annual Report ~//~ /mil <br />Map ((~~ //~ , <br />Remarks ~~ ; 5 J ohV,O~S~~ _ <br />Signed, ~ ~~~ <br />~~~ /J r., h. fly ~iL~ e w - <br />Gba..~ / ~h;J~ --- <br />~a /~Z - <br />1--- <br />~/~6 /£~~ <br />~. ~ <br />