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. ~~ <br />Permit No: _77-300 ' ~=~: <br />Anniversary Date: October 28 "•~~- <br />~~ <br />RECEIVED <br />ocr ~ ~~~~..~ <br />MINED LAND RECLAM,ePn~~ rwi~~,~p~ <br />Colo. Dept. of Nat~r~~ n~~,,,,,,,,, <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed ar <br />r/ <br />Remarks: <br />~; <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Map <br />Signature <br />