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• iii iiiiiiiiiiiiiiii <br />Permit No: 76-20 <br />Anniversary Date: May 27 <br />Operator: <br /> <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are <br />Remarks: <br />(Check box(es)) <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Map <br />Signature //ASSL~TANT (SECS~ETARY <br />