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i ~ <br />RECE9VE® <br />Permit No: 78-304 JAN 1 ~, )gg~ <br />Anniversary Date: November 13 L11NED LAND RECLAMATION DIVISION <br />Colo. Dept. of Natural Resources <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 the Colorado Mined Land <br />._ Reclamation Division for annual fees due <br />_ Annual Report <br />~":" J <br />Remarks: <br />Signature <br />~.~- ~" <br />r <br />