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'' ~ III II~IIIIIIII~~III <br />999 <br />Permit No: 82-112 <br />Anniversary Date: March 11 <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: <br />(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 />Remarks <br />Signed <br />