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• iii iiiiiiiiuiiiiii • <br />999 <br />Permit No: 79-70fi <br />Anniversary Date: ,~,,,,P 17 <br />Operator: <br /> <br />-~~'.;UjQ83 <br />- ~~; l; iA <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 t4ined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />_ Map <br />Remarks: The Annual Report and Map are being prepared now and will be <br />forwarded to you within 30 days. <br />d ~av~~'3 <br />~1r. ~' <br /> <br />