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<br />~_ <br />Permit No: 77-573 ) <br />Anniversary Date: March 22 <br />Operator: <br />• iii iiiiiiiiiiiii iii' <br />999 <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 />`/ Map <br />Remarks <br />RECEIVED <br />ON <br />Colo. Dept of Natural Resources <br />' / ~ll ~.u~+ Ai ~ <br />Signed <br />