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! • <br />Permit No: 79-2 <br />Anniversary Date: April <br />Operator: <br />Please complete the following 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 />Q ti on Division for annual fees due <br />0 Annual Report <br />O Map <br />Remarks <br />Signed, <br />e <br />n <br />a <br />O <br />U' <br />LL <br />H <br />Z <br />17~\\-0. <br />y p ~ etlHprm <br /> RECEIPT 'elate o-~- c ~zo 19~_ `-'~~~~Q <br /> Received From C c , cs, . ~ rt . . ~ ~ . CA . <br /> Address ~a3~„ .'t -~ ~ ~ , ~0.,~~• ~,_ ,.~_F~.-.~ ~t=.c~ z <br /> o ~? ~ ~ ~ _ ~ ~ ''~ ~ Dollars :•> ~ . o <br /> N <br />O <br />~o~~ <br />-:'i <br /> <br />For c•.. <br /> <br />-l.° <br /> ~ <br /> J W V_ f <br /> -I ~~~ ` <br />`' <br />O ACCOUNT HOW VAlD <br /> Z ? <br />~ AMT. OF <br /> • •~ <br />I ACCOUNT CASH <br /> =waU <br /> :~ I' W ~ AMT PAID CHECN~ <br /> -~UV1> BADUE E OBOERY By ~ I~l..•-rv. Cis <br /> <br />