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<br />s • <br />-.; ~-~ <br />...d .~ ~ ~ ..J <br />.j-. ..p .n ~.~._ <br />Permit No: 76-51 f~rIPY 2 ~~ )°83 <br />Anniversary Date: Play 8 ~ <br />~ • .a.,i,~rgl N.<T~ <br />Col^. Dent. ~` „ <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 pined Land <br />_ Reclamation Division for annual fees due <br />~. Annual Report <br />hlap <br />Remarks: <br />