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r.�r W Ili <br /> RECEIVED <br /> APR 101987 <br /> Permit No: 77_?i4 MINED LAND <br /> Anniversary Date: Marrh ?? RECLAMATION DIVISION <br /> Operator: <br /> Please complete the following and return this form with your fees and <br /> reclamation data. <br /> Enclosed are: (check boz(es)) <br /> Check or money order payable to Colorado Mined Land <br /> Reclamation Division for annual fees due <br /> Annual Report. <br /> Map <br /> Remarks <br /> Signed <br />