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<br />.. ~f <br />Permit No: 78=283 <br />Anniversary Date: n~;1 ~~ <br /> <br />Operator: <br />Please complete the following and return this form with your fees and reclamation <br />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 />Remarks <br />Signed, <br />~'~ ~~ `~ <br />~~ ~ c~'~ y-~~ <br />rT T'1 -+~ /~ <br />I1W~_~... ~lf _{lj l"- _.. ~_ <br />17,I:.SE:;b;;.,r;~ .. <br />..:irCi. L103$ <br />~-%' ~ sip <br />~~~^, ~ ~~ <br />