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~ M <br />Permit No: 81 •-158 <br />Anniversary Date: ~<1 flUdt'y <br />Operator: <br />Please complete the following and return this form with your fees and reclamation <br />data. <br />Enclosed are: (ChecJ: box(es)) <br />Check or money order payable to Colorado ;dined Land <br />rr-~~~t~,, R,~clamation Division for annual fees dve <br />Artn^aI Report <br /> <br />J ` <br />~' <br />- <br />' __ r, ~ ), , <br />~~~ <br />~ <br />Remarks ( <br />~ <br />G u ; Cam. <br />l~ J. ~ ~ ~~ <br />C <br />.,- <br /> r/' ~ ~( <br /> <br /> / .L - / l <br /> ! l' ; i . / . -f- - -fir- -. / <br />signed, <br />~~~~ a. (~~~ ~ <br />~~ ~ . <br />~~ <br />-T <br />