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<br />Permit No: 77-222 <br />Anniversary Date: January 25 <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 />JL Map <br />Remarks <br />v~ ,~ . <br />Signed ~ 1 <br />a ~6~~y <br />om.~-~ <br />~: << <br />