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_ • iii iiiiiiiiiiiiiiii • <br />999 <br />.. -.~ <br />Permit No: 78-279 / <br />Anniversary Date: November 22 <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to the Colorado Mined Land <br />Reclamation Division for annual fees due <br />~L Annual Report <br />Remarks: (~i,G/^ L~zYICL r-e~ /c~rM7/~G'~J LrzS /im~ CG~~~~~ie <br />/ ~ifi a~~C y~-~ G ~ se~~ . <br />l <br />~~ ~P <br />gnature <br />~'OV 30 119183 <br />.MINED LAND RECLAMATION DIVISIO <br />Colo. Dept. of Natural Resourc <br />N <br />es <br />Y~y./~~t ~~ir /Ii~i~ C7rI7~ W~ z.v~ C'e9 ~,~rzn..es o~/Q D/ <br />