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i r <br />Permit e7o: 77-526 <br />Ann`:r2 rsary Date: JdllUd ry <br />Operator: <br />Please completes t::e following and return this form with your fees and recIama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />Q ti on Division for annual fees due <br />Annual Report <br />Ffap <br />Remarks <br />Signed, <br />