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1 � <br /> 4 984 ' <br /> ?1P�lilitfO f�iCiF4�; tiUt;r ,�F', ' <br /> Permit No: 77-378 s,�vERTo,,, r'DH <br /> co_c <br /> Anniversary Date: April 23 <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 Colorado Mined Land <br /> Reclamation Division for annual fees due <br /> Annual Report <br /> Map <br /> Remarks <br /> Signed <br />