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'~ <br />Permit No: 77-297 <br />• FE6 819 <br />Anniversary Date: January 25 <br />Operator: <br />Please complete the foZZowing and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />[~_ ti on Division for annual fees due <br />Rnnual Report <br />1 JAI Map <br />Remarks <br />Signed, <br /> <br />