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r.~, <br />. <br />i , ~ .: <br />~,. . <br />Permit No: 82-40 <br />Anniversary Date: December 2 <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 />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />~•- <br />Map <br />Remarks <br />Signed <br />