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~11 ~~I~III~IIIII I~I <br />Permit No: 76-18 <br />Anniversary Date: October 17 <br />Operator: <br />r <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 />Map <br />Remarks ~n-.oX /(,~ C~~~t (rave fire-u re --uovtr;5~~{, <br />ftl[~ .a.~ ... a S r c-4s! iY /q,Jr9. .4t fhr~c ~r-~.. e, T /2y c <br />n~±. ~'~ Laif l.~wti/ ln4a~~~~.te~ Ic oDe-uCd <br />[T_~[ fe+.. -+. ~~ OM aLC ~v.n e. by ~.0007~a.1~I~~M. IS <br />Q~f~t e~~-ed_ <br />~y~~c~ <br />