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., <br />• <br />iii iiiiiiiiiiiiii- • <br />i~ <br />/%~/ <br />Permit No: 77-94 ~~~°~~~~® <br />Anniversary Date: December 20 JAN ~ g 1981 <br />Operator: MI CooLDept of vato allResourcesON <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 />-~/ , <br /> <br />Si <br />~~ ~ ~s <br />~~, j <br />~~ <br /> <br /> <br />