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. ~. ~ III IIIIIIIIIIIIIIII ~ <br />Permit No: 79-187 <br />Anniversary Date: January 23 <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 />_ Map <br />Remarks <br />• ~'lo~~ F7 ~® <br />~ ~;l n ~ l 5-15 <br />Colo. Dint. of i~!atural P,esourcesenl <br />