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<br />r <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />Camp Bird Ventures <br />td-82-090 <br />Camp Bird Colo ittc <br />12/07/88 <br /> <br />111/112 Enclosure <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />T~ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Map <br />Remarks: <br />Signature <br />(06/88) <br />0054f <br />f~ECElVED <br />~aN c ~ss9 <br />MINED LAND <br />(iECLAMATION DIVISION <br />