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<br />Permittee Name: Lake City Mines, Inc, <br />Operation Name: <br />Permit No: 78-91 <br />Anniversary Date: November <br /> <br />110 and 111 Attachment <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />ly'~xl Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />hocl Annual Report <br />Remarks: Please see attached <br /> <br />5i <br />(Rev. 5/84) <br />Doc. No. 1782 <br />