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<br />Permit No: 79-75 <br />Anniversary Date: May 14 <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (r_heck tux(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />® tion Division for annual fees due <br />® Annual Report <br />© Map <br />Remarks <br />Signed, /~~'~ <br />\~p/~~ <br />