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i ~ 'r <br />I <br />Permit No: 77_3n9 <br />Anniversary Date: October 27 <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: <br />-/ Check or money order payable to Colorado Mined Land <br />,/_ Reclamation Division for annual fees due <br />- Annual Report <br />I•lap <br />Remarks: ,flm.rr`aJ( ~,E~t~„~~-~t .r.,6,.~~ 1'/I -83 <br />