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*; `~~ • iii iiiiiiiiiiiu iii ~ <br />999 <br />Permit No: 77-23 <br />Anniversary Date: January <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />ti on data . <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />t~ ti on Division for annual fees due <br />~~ Annual Report <br />Map P~GTuR~ <br />Remarrks ~,~ ~/¢~' ;~ln ~.t-yv (~tt3~i. G~w~" ~ntv~ct~c.Q ./Z.E12yi;r- <br />O~ ~ 'N~o'T YN.a.hri. U Yyt 4.~ R S i4 ~ ~ -Q `~ C A /AT is ~v w 4.~. <br />-f~ fro-c~~. c1~ z~~.c R.~r , `1~~~.en.t,,,...~:G...: w u, 7~ ~.L~ <br />W~. o-n.~,. .~eaw~L.J ~u'y.-~ Qe'T ~8'Tv ,tJ~ze. ism ~.r..,ti <br />/~ ~S o P~wc,~9*LZ~( la... o~ R-u-~,.~ 02 R-~-i' ~-~~ .ir- ~;G~.Au.z ~ ~~ r.~~„ <br />Signed, lam/ <br />~. <br />v~ ~. <br />