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1 - • • <br />Permit No: 7g_ppp <br />Anniversary Date: March 1 <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 the Colorado Mined Land <br />~S Reclamation Division for annual fees due <br />Annual Report ~~~.c ~e1aw~ <br />Remarks: t~1~cx5L Gor+Scc~~c ~i5 gS bc~~ " t~fo-l-ic2 c~~ <br />_ ~ ~ <br />~.~-1-~ .-,-E- .~ <br />Coc-~,n~nE M~r,i~t4 ~J~.~c~'~~t,c,< ~'~ -1-1-, E. ~c~.,-„~„ <br />483 <br />ICi84 C"~a~~ c~,S <<~ (-Cf SC c'reE m~ninc, CoC Sown-~ c.C ~~ <br />I AMC r~Cp ~Lc~G _ <br />~-, „ ~- n <br />Signature ~c~-5 ~ <br />~~ ~' <br />