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<br />Permit No: 77-573 <br />Anniversary Date: March 22 <br />Operator: <br /> <br />Please complete the following and return t`tis 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 />ti on Division for annual fees due <br />® Annual Report <br />Map <br />Remarks <br />Signed, <br />1~Dl~t~i ~~2~ <br />:Dorman Roche <br />General Manager <br />Valco, Inc. <br />