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~ ,~ iii iiiiiiiiiiiiiiii , <br />- ~~ <br />~~ <br />Permit No: 81-121 ~~,`' ~ - ~ - ~ <br />Anniversary Date: July 23 /~", ~ ~98z <br />v~ <br />fti~INED ~ AI`:U Fl'_CL;'L,i;.IlLr.l <br />operator: CO'o. Dept. of f :::ur&i ~,~::o! ~ce~ <br />Please complete the following and return this form with your fees and reclamation <br />data. <br />Enclosed are: (Check box(es)) <br />hec. or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />r//Annual Report <br />Signed, ~~ ~ L J..~ 1'0 <br />~ ~ ~69a 8 <br /> <br />