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._ • • <br />RECEIVED <br />Permit No: tl1-107 <br />MAR 1 S i~~' <br />Anniversary Date: January 8 <br />r~~ ~. ,^ar~orY uIVISIDN <br />Operator: " ~'``"'°~ Kesources <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 the Colorado Mined Land <br />_ Reclamation Division for annual fees due <br />~ Annual Report <br />Remarks: <br />Signature <br />