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<br /> <br />-- <br />RECEIVED <br />Permit Na: 77-572 ~~A~ 2 ~ i,, . <br />Anniversary Date: P1dreh 22 . <br />A91KED LANC RECLAI.IATION <br />COLO. DEPT. O.` N.4?L' _4L R" L'==^ ~' <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />/ Check or money order payable to Colorado Mined Land Reclama- <br />m tion~Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />Signed, <br />~o, f~ sy/ <br />~, co ~io~-z- <br />