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i=~ <br />Permit No: 80-85 <br />Anniversary Date: F2bPUdY'y <br /> <br />operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />ti on Division for annual fees due <br />® Annual Report <br />Map <br />Remarks <br />Signed .,~ <br />~[.~ 4t~ <br />C`(~~ <br />