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<br />Permit No: Z7-1~7 ~ ~ ~ Z5 S <br />Anniversary Date: December 15 <br />Operator: <br /> <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 Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />j ~j Ma p <br />Remarks AGL OF THE .dBO/E /'TERAS d/QE .4TrAGHEC~. <br />Signed, X <br /> <br />