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- ~ ~~ III IIIIIIIIIIIIIIII <br />Permit No: 81-22 <br />Anniversary Date: May 2(1 <br />~ ~~, <br />_ ~~ <br />1JIAYw019~3,? <br />~.~ <br />t. _, i. L;I.Pi~A,~ i I~l~ <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check oor.(es)j <br />Check or money order payable to Colorado Niined Land <br />_ Reclamation Division for annual fees due <br />~L Annual Report <br />Remarks: <br />.S <br /> <br />off' <br />Siynature <br />