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1 <br />Permit No: 73-21 <br />Anniversary Date: May 23 <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 />III~~~~~~ YYY Check or money order payable to CeZorado Mined Land Reclama- <br />~'~}- ti on Division for annual fees due <br />[~ Annual Report <br />7~ Map <br />1~ <br />Remarks ~/~%~ <br />Si gned~~~`!'~/ C~~i~f~ <br />~~- <br />