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<br />Permit No: 77-560 RECEIVIED <br />Anniversary Date: FebrudP_y <br />~ MAR 091983 <br />• MINED LAND RECLAM<,TION <br />Operator: COLO. DEPT. OF NATURAL RESO:;RCES <br />Please complete the following and return this form with your fees .snd reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Remarks <br />Annual Report <br />Map <br />i) <br />Check or money order payable to Colorado Mined Land Reclama- <br />tion Division for annual fees due <br />Signed, <br />