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'~ • <br />Permittee Name: Lake City Mines Inc <br />Permit No: M-78-091-UG <br />Operation Name: GOLDEN WONDER MINE <br />Anniversary Date: 10 / O1 / 85 <br /> <br />110 and 111 Enclosure <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br />Signature <br />