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. S III IIIIIIIIIIIIIIII <br /> <br />r,~ <br />JAN 16 19fj <br />Permit No: 77-140 <br />Anniversary Date: January 15 <br />Operator: <br />MINED LAND RECLAMATION DIVISION <br />Celo. Dept. of Natural Resources <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 />-~~Ma <br />P <br />Remarks ,, ~~~- ~ ~~S '. 2 „~-~ -~ `w ~~s <br />'>r r ~ ~ ~ ti ~Ov t,c~ c ~ <br />Signed <br />/1.. <br />~~ <br />