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• ~ • ~ _ _ __ <br />• ~ ~'+ <br />.~u!! i ~ ~ga3 <br />Permit No: 78-327 <br />~il~!ED LAnD RECLA(v1,9~fICN <br />Anniversary Date: Ptay 14 Colo. Dept. of Naiural Resources <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 />~G Check or money order payable to Colorado 14ined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />y 'r~aP <br />Remarks: <br />~~ <br />Signature <br />