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Permit No: 77-451 <br /> Anniversary Date: February 15 <br /> Operator: <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 the Colorado Mined Land <br /> Reclamation Division for annual fees due <br /> Annual Report <br /> Remarks: y�o a c .�vJLl Jl2 On� <br /> -. ) <br /> D I_HPID R Pi.; :'AlIOi! D ,,,SION <br /> )i. Of <br /> Signature <br />