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<br />Permit :: o: 79-10 <br />Anni versarv Date: ~dll Udl'V ~5 <br />Operator: <br /> <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 />ti on Division for annual fees dve <br />® Rnnual Report <br />® M.ap <br />P.emar?s <br />Signed, ^ <br />~~inJ ~ 1~ <br />Blll B. \.iV$S <br />Project Manager <br />