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~~* s <br />Permit No: 80-49 <br />Anniversary Date: February 18 <br />Operator: <br />C~ <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 the Colorado Mined Land <br />_ Reclamation Division for annual fees due <br />- Annual Report <br />Remarks : ~ / n ~,r„n „ <br />.,~_ ~.. <br />MINED LAND RECLAMATION DIV~_N ND 1229 <br />1313 Sherman Sveet Room 4.~ <br />Denver, CO 80]03 DATE 3 Z ~s~ <br />(303) 866-3567 <br />RECEMED FROM <br />'~(~ ~{. ~~D~DO ~~ DOLLARS $ S O ~ U <br />THE SUM DF ~ D s" <br />G OSOCo ~OCK <br />~o Qin~~ 1 LLII <br />FOR ~' <br />AMOUNT OF ACCOUNT...... $ ~` <br />AMOUNT PAID ......... .... . $ <br />ll BALANCE DUE ~ ~ ~ ~ ~ ~ ~ ~ "' $ _ -- <br />'gnature <br />DECEIVED <br />MAR 12 1984 <br />BY <br />~~anl¢ ~oul. <br /> <br />MINED LAND RECLAMATION DIVISION <br />Colo. Dept of Natural Resources <br />