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'. -. <br />Permit No: 80-3 <br />Anniversary Date: January 24 <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 far annual fees due <br />Annual Report <br />Remarks: .~ p J ~~ ,oU Drt:/ ili vcv <br />/~' / 9 ~.7 wi'r/> dO n T,firil ~'h'A.yG~s' A~1.a ~~F <br />