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• <br />Permit No: 79-189 <br />Anniversary Date: June 1 <br />I <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />Q ti on Division for annual fees due <br />Annual Report <br />® Map <br />Remarks $ee map and report <br />Signed, ~~rG~G~Gf~S _ " <br />RECEIPT <br />Received From_ <br />Address +2 -ti <br />Date 19_~Z,_ <br />~....._ _ ~. o _..Cl ~4 C, n... _. 0 Cn <br />Dollars <br />ACCOUNT <br />AMT' OF USH <br />ACCOUNT <br />AMi. PAID CHECI <br />5,i <br />~_ <br />BK806 <br />