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Permit No: 77-500 <br /> Anniversary Date: June 29 <br /> Operator: <br /> Please complete the following and return this form with your fees and <br /> reclamation data. <br /> Enclosed are: (Check Dox(es) ) <br /> Check or money order payable to Colorado Hined Lana <br /> Reclamation Division for annual fees due <br /> Annual Report <br /> / <br /> Remarks: �� .,a � ��ez;Q a<i�l e OW-2 " <br /> S'l gnature <br />