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F'__~ <br />i <br />I Permit No: an-77 <br />Anniversaru Date: Februaru 2 <br />Operator: <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 moneu order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Remarks <br />Signed, <br />-•~" <br />