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i .- • a <br />Permit No: 79-166 <br />Hnniversary Date: September 4 <br />~ Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(esj) <br />Check or money order payable to Colorado Minea Land C ~/ <br />_ Reclamation Division for annual fees due ~E~'G~ V ~® <br />Annual Report SEP ? ~ 1983 <br />MINED LAND RECLAMATION DIVISION <br />Colo. Dept. of Natural R:soucces <br />Remarks: <br /> <br /> MINED LAND RECLAMATION DIVISI J ~ I p Q 5 3 8 <br />1313 Sherman Street Room 423 ~ V <br /> Denver, CO 80203 DATE q ~ is ~3__ <br />(303) 866-3567 <br /> RECEIVED FROM ~~ ~ <br /> C~ <br />THE SUM OF a/~ '~ DOLLARS $ SC> ~ CX~ <br /> ^ cns~+ <br /> A <br />FOR Qom,. ~4 -19' Igo ~O SZ 1 Orna GK <br /> <br /> AMO ;NT OF ACCOUNT...... $ ~~~~~ /~'O~I <br />`(JA <br /> AMDI.JfJT PAID ................ $ <br /> ~_ <br />BALANCE DUE ............... $ BY ~ ~ (1M- r /1Ct-~- <br /> <br />gnature <br /> <br />