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<br />Permit No: 81-20 <br />Anniversary Date: May 6 <br />III IIIIIIIIIIIIIIII <br /> <br />IJI r51 1 ~ IJOZ <br />operator: MINED LAND RECLACJIATIDN <br />Co'o. dent. at .'aturzl Reso~~rce~ <br />Please complete the following and return this form with yovi fees an~ reclamation <br />data. <br />Gnciosed are: (Chac~c pox(es)) <br />GSeck or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />~~ A+xnval Report <br />Remarks <br />S(~'` d, <br />v . ~. ~~~~ <br />om ~-~ - ., <br />