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,: <br />• <br />~ III IIIIIIIIIIIIIIII <br /> <br />Permit IJo: ~~_ua 1 i~9, <br />Annl VerSary Date: NOYEllLr 3n L,li'I ~l I ~. ~.'n _.=~I; " ,-f','' ;~~nSi(lPJ <br />Operator: ~ /~~Q <br />Please complete the following and return this form with your fees and ~'/l /CI/ ` / <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />.- Check or money order payable to the Colorado Mined Land <br />mac. Reclamation Division for annual fees due <br />Annual Report <br />Remarks: We have not this year, and do not anticipate next year to exceed <br />~~ permit limits. <br />Maim still active. No reclamation planned at this time. <br />Signature <br />~~ ~ G <br />