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~~ ~ III IIIIIIIIIIIIIIII • <br />999 <br />Permit No: <br />Anniversary Date: Januarv 23 <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 />Check or money order payable to Colorado Mined Land <br />_ Reclamation Division for annual fees due <br />Annual Report <br />~./ NI ap <br />p~ ~ ~~~ <br />~ ~~-4, ~j~~a <br />