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' '~ ~ III IIIIIIIIIIIIIIII ~ <br />Permit No: _7g-91 <br />Anniversary Date: November <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 the Colorado Mined Land <br />xx.. Reclamation Division for annual fees due <br />~ Annual Report <br />Remarks: Please see attached <br /> <br /><<l/~rJ~r3 <br />~. ~- ~ <br />t%,`!~ <br />7 ~- Ya <br />