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.• <br />Permit No: 81-132 <br />Anniversary Date: November 5 <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check boxes <br />Check or money order payable to Colorado Mined Land <br />,_ Recla+nation Division for annual fees due <br />JL Annual Report <br />Map <br />Remarks <br />%, <br />Signed ~/_~/O~ / ~'~~~~/J,1 /] ' <br />