Laserfiche WebLink
=: s • <br />Permit No: 78-323 <br />Anniversary Date: November 22 <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: <br />v ~ <br />c .. 1 <br />Signature <br />