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<br /> <br />Permit i~o: 77_75 <br />Anniversary Date: September 27 <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 /> <br /> <br />Remarks: <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />/9~~ <br />y)~cs ~G'Pr ~ ~~~ ~yo~e ~vv ti~ C ~v b <br />