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<br />• i <br />112 Attachment <br />I Permittee Name: Colorado Lien Como <br />Operation Name: <br />Permit No: 77-301 ~•~ <br />Anniversary Date: October 27 <br />Please complete the following and return this form with your fees ami <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 />I I Annual Report <br />~-I Map <br />Remarks: <br />(Rev. 5/84) <br />Doc. No. 1805 <br />~; ~,;~t <br />~i . <br />