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'~ iii iiiiiiiuiiu iii • <br />999 114. Encl osure <br />Permi ttee Name: ~T ~ ~ ~ ~ ~ 5~.+-~> =. Ga~~s ~ ~~ , <br />Permit No: rn _ ~ a - /q I <br />Operation Name: -~-~.+ar_~ qe~~ PrT <br />Anniversary Dat ocT. ~3 1qg~ <br />Please complete the following and return this forth with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />V Check or money order payable to Colorado Mined Land Declamation <br />Division for annual fees due <br />Annual Report <br />Remarks: /`-~ Ntil~~-/tom RGPoR ,- ~/v ~ ~_~- .3~ <br /> <br />~sECLA~JATlON DIVISIOhJ <br />lKev, uc~oil <br />5257E r ,(~ <br />