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.. . <br />Permit No: 77-252 <br />Anniversary Date: January 13 <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 Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />iNap <br />Remarks <br />Signed <br />R~~~j~~~ <br />~Ari i r, »a~~ <br />('dINED LAND RECLAMATION OIUISIOtI <br />Colo. Dept. of Natural Resources <br />