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<br />. ~ III IIIIIIIIIIIIIIII • <br />~~ 999 <br />Permit No: 81-307 <br />Anniversary Date: December 3 <br />Operator: <br />Please complete the following and return this form with your fees and <br />recla,nation 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 />Map <br />Remarks <br />Signed <br />~ a-( i 5 / f3 <br />~ "~' <br />~ (~ <br />., - <br />Cc!".~; ... cl .~ . r~ ~:rces <br />