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iii iiiiiiiiiiiiiii • <br />• <br /> <br />Permit No: 77-132 <br />Anniversary Date: January 16 <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 Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Map <br />Remarks ANIJUAL K4PoRr AND rIRP wiu. 4~ FILE 5£PM:~fE.I.Y <br />Signed <br />