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. : • • ~ ~.: <br />Permit No: 80-224 <br />_' <br />Anniversary Date: January 6 <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 />~L Check or money order payable to Colorado Mined Land <br />_ Reclamation Division for annual fees due <br />_.-. Annual Report <br />Map <br />Remarks Other iteas xili fol~ox xithin 30 days. <br />' ned <br />~, ~-~ ~ <br />