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• <br />Permit No: <br />Ar7i versary Date: <br />Februa <br />CDerator: <br />Please complete the following and return this form with your fees a;~d reclama- <br />tion data. <br />inclosed are: (Check box(es)) <br />.ae:narks <br />77-560 <br />Chec3: or money order pauable to Colorado N_ined L.3nd Reclama- <br />ti on Division for annual fees due <br />Annual Report <br />~J'/ % <br />t-l~--~ ~.•ap <br />Signed, <br />1 <br />z c^'`-~% <br />