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III IIIIIIIIIIIIIIII <br /> Permit No: 77-573 <br /> o <br /> Anniversary Date: March 22 <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 /> tion Division for annual fees due <br /> ® Annual Report <br /> ® Map <br /> Remarks fnPp ComwG yNo62 SEPA244T-) C'.oOE2 F2oM <br /> LA-22y d P'fL\Ati <br /> CMUu acxDx46A T 2Nc. <br /> 9999 b il� PvE <br /> 'A2JaOA F 0004- <br /> Si gned, <br />