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. „ iii iiiiiiiiiiu iii <br />Permit No: 77-227 <br />Anniversary Date: February <br />operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(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 ~ U~11- Q~'e-I- ST[l~ I~ '7V~- QY©C~-SY d'~' mltnltig ~"~ ~~~~ <br />5 l l'~-'~ V cC14 ~'~t ~ ~~ L~~ e~_beg rcti. <br />Signed, <br />~J~ 1 <br />~-a'-l <br />