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<br />Permit No: 77-559 <br />dnni versarv Date: February 22 <br /> <br />Operator: <br />Please complete the following and return this form with yoar fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Remarks <br />Check or money order payable to Colorado Mined Land Reclama- <br />tion Division for annual fees due <br />Annual Report <br />Map <br />~ w 0 <br />Signed, `~Y <br />