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~~ <br />i <br />Permit No: 80-249 ~~~~~~~"® <br />Anniversary Date: February 4 FEB ~ 15',•! <br />MINED LAND REC1A1^ari~~• ~"~~;tD1t <br />Operator: Cola Dept. et ,~~,~. ,;, ;~_, <br />....e~ <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 the Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />X12! ~~,~r~~~-~-` <br />~ Signature <br />~/~~~. ~ <br />~~ <br />