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I ' <br />Permit ,vo: 77-3 1 <br />Anniversary Date: f)rrnher <br />Operator: <br />Please complete the following and retvrn this form with your fees and reclama- <br />tion data. i <br />Enclosed are: (Check bo.r(es)) ~ <br />_, <br />Check or money order payable to Colorado Mined Land Reclama- <br />Q ti on Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />Signed, <br />RECEIVED iJOV 1 0 1182 <br />