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• <br />Permit No: 81-229 <br />Anniversary Date: December 1£1 <br /> <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 /> <br /> <br /> <br />Remarks <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Map ~I,, IWNED LAND RECLAMATION DIVIS'VV <br />f313 Sherman Street Room 4Z. <br />Denver, CO 80]03 <br />(303} 866-3567 <br />S i RECEIVED FROM <br />THE SUM Ofd ~ ,u G~ <br />FDR <br />AMOUNT OF A OUNT...... $ <br />AMOUNT PAID ................ $ <br />6 <br />~' BALANCE DUE.......... . $ BY <br />F....r...r.~...~.,ow.~...d....~.......,..~.. ...-.-- ...... <br />N°_ 1046 , ~ <br />DATE ~~.~.-~9 g-~ <br />I ~ V I ~/ ECK <br />a ^MO. <br />~tiQYI~ <br /> <br />Jigned <br />