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,~ - <br />N <br /> <br />Permit Na: 77-304 <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 (GJ.~i ~w ~ <br />~~ ~~ <br />Map <br />Remarks Q F(` G I \/ C I'l <br />MINED LAND RECLAMATION DIVISION <br />(1010. Denl. 0} N9tIlIBI Rocnurroc <br />~~ <br />Signed <br />~Le~Cx,u V~~L~ <br />f~IAR 7 i98~1 <br />Anniversary Date: March l <br /> <br />