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~ III IIIillliilillill <br />999 <br />Permit vo: 77-552 <br />Anniversary Date: January 25 <br /> <br />I~ <br />~l~ <br />Operator: <br />Please complete the following and return this form with your fees Ind reclamation <br />data. <br />Enclosed are: (Check boxtes)) <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Remarks RECEIVED <br />41983 <br />NED LAND RECLAMATION <br />COLO. DEPT. OF NATURAL RESCI`~rcc <br />Signed, <br />- - ~ <br /> <br />