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• Ill lIIIIIIIIIl11111 <br />Qgrmit No: 79-59 <br />Anniversary Date: November 20 <br />~~~GG v~ <br />JAf~! ~~ 10~,+ <br />191NED LAND RECLAf:?ATfOA~ 0!~aSION <br />Celo. Dso!. of A~~rural fie:.~wces <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br /> <br />Remarks <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Map <br /> <br />Signed <br />