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<br /> <br />Permit No: 77-321 <br />Anniversary Date: February 17 <br />Operator: <br /> <br />Please complete the following and return this form with your fees and reclamation <br />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 />• Remarks <br />si gne d, <br /> <br />